Page 9 - Ally Office Solutions - 2023 Benefit Guide

Dental Option:

Dental Select

2022 Rate — Per Pay Period

Weekly Employee Cost Dependent Information
Ally Office Solutions offers employees the op-
Employee Only $ 8.04
portunity to cover their spouse and de-
Employee + Spouse $27.42 pendent children. Children can join or

Employee + Child(ren) $35.46 remain on a parent’s dental plan until age 26.
When a child turns 26, they will lose dental
Employee + Family $52.98 coverage on the last day of their birth month.

(In-Network) Amount Paid
Type of Service (Out of Network Paid at the 90th Percentile of
Routine & Customary costs)

Preventive Services Covered at 100%; No Deductible

Basic Services Covered at 80% after Calendar Year Deductible
Major Services Covered at 50% after Calendar Year Deductible

Calendar Year Deductible $50 Individual / $150 Family

Annual Maximum $1,500 per person

Orthodontic Services to age 19 Covered at 50%
Waiting Period None

Type of Service Benefit Description

Preventive Services Oral Exams, Cleanings, X-rays, Sealants, Fluoride Treatment

Basic Services Restorations and General Services

Simple Extractions, Crowns, Bridges, Dentures, Endodontics,
Major Services
Periodontics and Oral Surgery
Annual Maximum Applies January 1 to December 31

NOTE: This is only a brief overview. Please see Benefit Summary for more details.
Website: www.myuhc.com or Customer Service : 866-633-2446

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