Benefits at a Glance

The Langdale Company Employee Benefit Plan offers Dental Benefits to Dependent Children to the age of 26.  Coverage will end at the end of the month that a covered dependent turns 26 years of age.

Annual maximum out of pocket is $1,500.

Effective January 1, 2024, Orthodontic Treatment is a covered dental service with a Lifetime Maximum of $2,000 per covered member and 50% Coinsurance.

Plan Document

This Dental plan is no longer a closed plan and members can be added or changed during annual open enrollment periods. Enrollment is offered when employee is first eligible or if there is a HIPAA Enrollment Event as defined in the Plan Document / Summary Plan Description.

Premiums

Coverage Tier Weekly Semi-Monthly
Employee Only $2.06 $4.43
Employee + 1 Dependent $6.51 $14.11
Employee + 2 or More Dependents $13.11 $28.41

Schedule of Benefits

Type I Services Type II Services Type III Services
During the 1st Year 100% of UCR 80% of UCR 50% of UCR
During the 2nd Year 100% of UCR 80% of UCR
Thereafter 100% of UCR 80% of UCR
Waiting Periods None None None
Benefit Maximum $1,000.00 per Policy Year per Covered Person

UCR – Usual, customary and reasonable – Commonly charged fees for dental services in a certain area.

Type III dental service tiers have been eliminated and will be paid at 50%

The above information is provided as a summary only.

For a detailed list of Type I, II, and III services, please refer to the Plan Document tab.

Claims

Dental benefit claims are paid by TLC Benefit Solutions, Inc., Post Office Box 947, Valdosta, Georgia, 31603-0947, (229) 249-0940 or (877) 949-0940.

Refer to your Plan Document / Summary Plan Description for complete details and limitations.