Summary of Benefits and Coverage
Summary of Benefits
Plan Booklets
Member Brochures
COBRA
Covered Drug Lists
Program Information
Summary of Benefits
Plan Booklets
Plan Brochures
FAQs
Find a Dentist
Summary of Benefits
Plan Brochures
Certificates
Health Savings Account
Flexible Spending Accounts
Basic Life and AD&D
Short-term Disability
Long-term Disability
Leave of Absence
Supplemental Life and AD&D
Accident
Hospital Indemnity
Critical Illness
Supplemental Short-term Disability
Claims Submission
LifeMart
Legal Plan
Employee Assistance Program
Family-Planning Benefit
401(k) Plan
January Wellness Materials
Healthy Choices. Healthy You. (English) →
Healthy Choices. Healthy You. (Spanish) →
February Wellness Materials
Pathway to a Healthy Diet (English) →
Pathway to a Healthy Diet (Spanish) →
March Wellness Materials
Eating Healthy on a Budget (English) →
Eating Healthy on a Budget (Spanish) →
Compliance Notice
Medicare Part D
Wrap Summary Plan Description
Summary Annual Report
Section 125 Cafeteria Plan Document
A Summary of Benefits and Coverage (SBC) has been designed to assist you with better understanding the coverage being offered to you, and to allow you to compare coverage options.
The SBC is available on www.99onlybenefits.com. A paper copy is also available, free of charge, by calling 1-323-881-9968.
All benefit plans are governed by master policies, contracts, and plan documents. In the event of any
inconsistency between the information contained herein and the applicable plan documents, the
provisions of the plan documents shall prevail. The 99 Store reserves the right to amend, suspend or
terminate any benefit plan, in whole or in part, at any time. The authority to make such changes rests
with the Plan Administrator.
In the event of any conflict between the content contained herein and
the Summary Plan Description (SPD),
the provisions of the Summary Plan Description (SPD) shall prevail.
© Piper Jordan, LLC. All rights reserved.
2022/2023
Benefits Hub
We have developed this Benefits Hub for
you as your benefits one-stop-shop – available to you year-round! Get access to
things like plan details, vendor contact information, and helpful compliance
documentation.
At the bottom of each benefit tile, you will see radio buttons – Documents,
Contacts, and View Plan Detail. Click within each button to access key benefit
detail.
To get started, click a Benefit Icon to the left or just start scrolling.
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Monthly Wellness
BRAND NEW wellness topics delivered monthly.
Medical Plans
with 
We are offering you 3 Aetna plans. Make sure to View Plan Detail before enrolling!
Premier Care Lifestyle HSA
Network Coverage:
In-Network only
Deductible:
Generally, you must pay all of the costs from
providers up to the deductible amount before this plan begins to pay.
Services covered before you meet your deductible include In-network
preventive care.
$2,700 (I) / $5,400 (F)
Doctor Visits:
30% after deductible
Generic Drugs:
$10 after deductible
Premier Care Traditional
Network Coverage:
In-Network only
Deductible:
$1,000 (I) / $2,000 (F)
Doctor Visits:
$25 copay
Generic Drugs:
$15 copay
Flex Choice POS
Network Coverage:
In- and Out-of-Network Coverage
Deductible:
$1,500 (I) / $4,500 (F)
Doctor Visits:
$30 copay
Generic Drugs:
$10 copay
Pharmacy
MedImpact Prescription Drug is included with each Aetna medical plan. View covered drug lists under Documents.
Dental Plans
You are offered two dental plans! A DHMO with lower premiums and a Cigna Advantage
DPPO Network plan with an
annual benefit of $2,000.
If no action is taken during open enrollment, your plans will be automatically
transitioned to Cigna.
Dental HMO
Network Coverage:
In-Network Only
Deductible:
$0
Basic:
Copay schedule
Major:
Copay schedule
Orthodontic:
Copay schedule
Dental PPO
Network Coverage:
In- and Out-of-Network Coverage
Deductible:
$50 (I) / $150 (F)
Basic:
80% after deductible
Major:
50% after deductible
Orthodontic:
50% no deductible
Vision Plans
We offer you 2 vision plans: VSP Base and VSP Buy-up Premier. Use the buttons at the bottom to view more information about each plan.
Vision Base
Network Coverage:
In- and Out-of-Network Coverage
Wellness Exam:
$10
Prescription Glasses:
$25
Frame Allowance:
$150
Contacts:
$150
Vision Buy-Up Premier
Network Coverage:
In- and Out-of-Network Coverage
Wellness Exam:
$10
Prescription Glasses:
$25
Frame Allowance:
$200
Contacts:
$200
Health Savings Account
A health savings account (HSA) is a powerful tool that helps you save on healthcare
expenses now and in the future.
An HSA, paired with our Premier Care Lifestyle HSA plan, is
like a normal savings account – the money is yours and never expires. And, your
contributions to your HSA are tax deductible!
2022 Limits
Individual Limit:
$3,650
Family Limit:
$7,300
Catch-Up Contributions:
If you’re age 55 and older, you can contribute an
additional amount annually as defined by the IRS each calendar
year.
$1,000
2023 Limits
Individual Limit:
$3,850
Family Limit:
$7,750
Catch-up Contributions:
$1,000
Flexible Spending Account
You can elect to have a portion of your paycheck contributed pre-tax to a flexible
spending account (FSA) to pay for qualified medical and dependent care expenses.
Health Care FSA Eligibility:
Premier Care Traditional ACO or
Flex Choice POS medical plans
Dependent Care FSA Eligibility:
All medical plans
Health Care FSA
Helps you pay for expenses such as co-payments, dental, and vision.
Annual Contribution Limit:
$3,050
Rollover:
None
Dependent Care FSA
Helps you pay for expenses such as day care, preschool, and elderly care.
Annual Contribution Limit:
$5,000
Rollover:
None
Employee Assistance Program
Feel Supported. If you are feeling stressed or are worrying about your family or money, connect up to 5 times per issue with a licensed counselor for help.
Life & Disability
We provide these benefits at no cost to you. You do not need to re-enroll in these benefits each year in order to receive them. No action required.
Included Benefits
✓ Life and Accidental Death & Personal Loss
✓ Short-Term Disability
✓ Long-Term Disability
Financial Protection
Protect your life — and everything in it
By signing up for the right mix of benefits, you can plan for less financial risk
and improved wellness. That’s the power of a comprehensive benefits package. See how
the right combination of products can help you protect everything that matters.
Included Benefits
✓ Supplemental Life and Accidental Death & Personal Loss
✓ Accident
✓ Hospital Indemnity
✓ Critical Illness
✓ Supplemental Short-Term Disability
✓ Legal
401(k)
A plan where you may contribute tax-free dollars to save for retirement.
With a traditional 401(k), employee contributions are deducted from gross income, meaning the money comes from the employee's payroll before income taxes have been deducted. As a result, the employee's taxable income is reduced by the total amount of contributions for the year and can be reported as a tax deduction for that tax year.
No taxes are due on the money contributed or the investment earnings until the employee withdraws the money, usually in retirement.
Family-Planning Benefit
By Progyny™
Progyny knows the road to parenthood can be challenging — they were founded by people who’ve faced obstacles to fertility first-hand. That’s why they partner with the nation’s leading fertility specialists to bring you a smarter approach with better care and more successful outcomes. Progyny is designed so that more options are available to anyone who wants to have a child.
Included Benefits
✓ Access to a premier fertility specialist network
✓ Integrated fertility medication benefit
✓ You'll get your own Patient Care Advocate
✓ And more!
Compliance
Your hub for compliance information, forms, and contacts you may not have found elsewhere.
A Summary of Benefits and Coverage (SBC) has been designed to assist you with better understanding the coverage being offered to you, and to allow you to compare coverage options. The SBC is available on www.99onlybenefits.com. A paper copy is also available, free of charge, by calling 1-323-881-9968.
The 99 Store permits INSURERS to offer employees of The 99 Store certain voluntary insurance programs. Whether you choose to enroll in any of these programs is completely optional and voluntary. The 99 Store does not make a contribution towards the cost of these programs and employees pay the full cost of premiums on an after-tax basis. The 99 Store does not sponsor, maintain, endorse, recommend, or promote these voluntary programs. The 99 Store'S involvement regarding these voluntary insurance programs is strictly limited to allowing the insurer access to employees to publicize these programs and The 99 Store may perform certain ministerial functions such as payroll deduction and forwarding employee premium payments to the insurer. The 99 Store does not receive any consideration in the form of cash or otherwise in connection with the program, other than reasonable compensation, excluding any profit, for administrative services actually rendered in connection with payroll deductions. Accordingly, these voluntary insurance programs are not subject to ERISA and related regulations. All questions or claims regarding these programs should be directed to the insurer.
All benefit plans are governed by master policies, contracts, and plan documents. In the event of any inconsistency between the information contained herein and the applicable plan documents, the provisions of the plan documents shall prevail. The 99 Store reserves the right to amend, suspend or terminate any benefit plan, in whole or in part, at any time. The authority to make such changes rests with the Plan Administrator.
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