Page 11 - Ally Office Solutions - 2023 Benefit Guide
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Vision Option:
Dental Select
2022 Rate — Per Pay Period
Dependent Information
Weekly Employee Cost Ally Office Solutions offers employees the op-
portunity to cover their spouse and depend-
Employee Only $ 1.16
ent children.
Employee + Spouse $2.90 Children can join or remain on a parent’s
dental plan until age 26. When a child turns
Employee + Child(ren) $3.10
26, they will lose dental coverage on the last
Employee + Family $5.62 day of their birth month.
Benefits (In-Network) Plan Coverage
Copays:
Well Vision Exam $10 Copay
Materials $10 Copay
Contact Lens Exam (fitting and evaluation) Up to $40 Copay
Frequency: (January 1st through December 31st)
Exams Every 12 Months
Lenses Every 12 Months
Frames Every 24 Months
Contact Lenses Every 12 Months
Standard Lenses:
Single Vision Covered in Full after Copay
Lined Bifocal Covered in Full after Copay
Lined Trifocal Covered in Full after Copay
Standard Progressive Lenses $75 Copay
Premium Progressive Lenses $75 - $120 Copay
Custom Progressive Lenses $20% off any balance over $120
Frames:
Frames Allowance $100 Retail Allowance then 20% off any balance over $100
Contact Lenses in lieu of eye glasses, materials only:
Frequency Every 12 Months
Lens Allowance $115 Retail Allowance then 15% off any balance over $115
NOTE: This is only a brief overview. Please see Benefit Summary for more details.
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