2024 Plan Design
Plan Documents
- 2023 Medical Summary Plan Description
- 2025 Summary of Material Modifications
- 2025 Summary of Benefits and Coverage
- 2024 Medical Summary of Benefits & Coverage
- 2024 Summary of Material Modifications
TLC Benefits Claim Portal
Langdale employees can login to the TLC Benefits portal for information about claims, EOBs, and plan information for medical and dental plans.
Rates
Weekly Rates – Single Coverage
| Life Ins. Class | Salary Range | Premium | w/ Tobacco Surcharge | w/ Diabetes Surcharge | w/ Tobacco & Diabetes Surcharges |
| 30,000 | $15,000-$21,999 | $25.67 | $44.13 | $34.90 | $53.36 |
| 40,000 | $22,000-$29,999 | $27.10 | $45.56 | $36.33 | $54.79 |
| 50,000 | $30,000+ | $28.49 | $46.95 | $37.72 | $56.18 |
Weekly Rates – Family Coverage
| Life Ins. Class | Salary Range | Premium | w/ Tobacco Surcharge | w/ Diabetes Surcharge | w/ Tobacco & Diabetes Surcharges |
| 30,000 | $15,000-$21,999 | $111.21 | $129.67 | $120.44 | $138.90 |
| 40,000 | $22,000-$29,999 | $113.83 | $132.29 | $123.06 | $141.52 |
| 50,000 | $30,000+ | $116.33 | $134.79 | $125.56 | $144.02 |
Semi-Monthly Rates – Single Coverage
| Life Ins. Class | Salary Range | Premium | w/ Tobacco Surcharge | w/ Diabetes Surcharge | w/ Tobacco & Diabetes Surcharges |
| 30,000 | $15,000-$21,999 | $55.62 | $95.62 | $75.62 | $115.62 |
| 40,000 | $22,000-$29,999 | $58.72 | $98.72 | $78.72 | $118.72 |
| 50,000 | $30,000+ | $61.74 | $101.74 | $81.74 | $121.74 |
Semi-Monthly Rates – Family Coverage
| Life Ins. Class | Salary Range | Premium | w/ Tobacco Surcharge | w/ Diabetes Surcharge | w/ Tobacco & Diabetes Surcharges |
| 30,000 | $15,000-$21,999 | $240.94 | $280.94 | $260.94 | $300.94 |
| 40,000 | $22,000-$29,999 | $246.62 | $286.62 | $266.62 | $306.62 |
| 50,000 | $30,000+ | $252.05 | $292.05 | $272.05 | $312.05 |
Pharmacy Plan
ProCare Rx will continue as the pharmacy benefit manager.
Non-Preferred Pharmacy Providers include the following pharmacies at which you will pay a higher copayment: CVS, Walgreens, Rite-Aid, Wal-Mart, Target, and SAM’S.
Chancy Drugs is the Health Plan’s preferred pharmacy.
- You may fill a 90-day prescription at any Chancy Drugs location (Lake Park, Valdosta, Hahira, Adel, and Moultrie)
- Chancy Drugs is the Plan’s only approved Compounding Pharmacy
Specialty Drugs
Specialty Drugs are provided through Specialty Concierge Services. Covered Persons are required to provide certain documentation to access and qualify for these services.
The International Drug Program
Your Plan has an International Drug Formulary for certain medications. Drugs obtained through this program are at no cost to the Covered Person. If these medications are obtained outside of the International Drug Program, the Covered Person is responsible for 50% of the Allowed Amount, non-applicable to your Out-of-Pocket.
