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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.
30% after deductible
First 3 PCP visits FREE/$25 copay
$30 copay
$2,700 (I) / $5,400 (F)
$1,000 (I) / $2,000 (F)
$1,500 (I) / $4,500 (F)
$7,000 (I) / $14,000 (F)
$3,000 (I) / $6,000 (F)
$7,000 (I) / $14,000 (F)
In-Network Benefits | Premier Care Lifestyle HSA |
Premier Care Traditional ACO |
Flex Choice POS |
---|---|---|---|
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.
Individual/Family |
$2,700 / $5,400 | $1,000 / $2,000 | $1,500 / $4,500 |
Out-of-Pocket Maximum:
The out-of-pocket limit is the most you could pay
in a year for covered services.
Individual/Family |
$7,000 / $14,000 | $3,000 / $6,000 | $7,000 / $14,000 |
Preventive Care | 100% | 100% | 100% |
Specialist Visit | 30% after deductible | $50 copay | $50 copay |
Urgent Care | 30% after deductible | $50 copay | $50 copay |
Emergency Room | 30% after deductible | $250 copay | $300 copay |
Pharmacy
Generic Formulary/Brand Non-Formulary Brand Specialty |
$10 copay after deductible $40 copay after deductible $70 copay after deductible 30% up to $150 max after deductible |
$15 $40 $75 $150 |
$10 $40 $75 20% up to a $250 max |
Weekly Premium
Employee-Only Employee + Spouse Employee + Child(ren) Family |
$19.84 $70.44 $59.54 $103.98 |
$45.00 $102.30 $85.81 $151.22 |
$58.98 $122.70 $111.80 $181.97 |
Aetna
Do you take prescription medications regularly? With MedImpact Direct, you can have them conveniently delivered right to your door. No more standing in line at the pharmacy.
✓ Medications delivered anywhere in the U.S.
✓ Free standard shipping
✓ Up to a 90-day supply of your medications
✓ Access to expert pharmacist advice
Specialty medications are complex and used to treat chronic conditions such as cancer or
hepatitis C.
✓ MedImpact will call you to get started
✓ Your doctor will fax your medication referral to MedImpact
✓ MedImpact's dispensing pharmacy will call you to start therapy
MedImpact
In-Network Benefits | Aetna Dental HMO | Aetna Dental PPO | |
---|---|---|---|
Network Options | Aetna Dental HMO Network | Aetna DPPO Advantage Network | Non-Network |
Annual Deductible | $0 | $50 / $150 | |
Calendar Year Maximum | N/A | $2,000 | |
Basic Services | Copay | 80% after deductible | Deductible, then 50% of reasonable and customary charges |
Major Services | Copay | 50% after deductible | Deductible, then 50% of reasonable and customary charges |
Orthodontic Services | Copay | 50% no deductible | Deductible, then 50% of reasonable and customary charges |
Orthodontia Lifetime Max | N/A | $2,000 | |
Weekly Premium
Employee-Only Employee + Spouse Employee + Child(ren) Family |
$2.24 $4.71 $5.61 $8.08 |
$5.58 $11.09 $14.43 $19.85 |
Find a Dentist
Summary of Benefits
Compliance
Cigna
In-Network Benefits | VSP Base |
VSP Premier |
---|---|---|
Copay | $10 exam | $10 exam |
Prescription Glasses | $25 | $25 |
Lenses | Included in Prescription Glasses | Included in Prescription Glasses |
Frames | $150 allowance / $80 Costco | $200 allowance / $110 Costco |
Contact Lenses in lieu of glasses |
$150 | $200 |
Weekly Premium
Employee-Only Employee + Spouse Employee + Child(ren) Family |
$0.64 $1.26 $1.35 $2.14 |
$1.56 $3.10 $3.33 $5.29 |
VSP
HSAs are savings accounts funded by pre-tax contributions from your paycheck. These accounts
earn interest tax free and can be used to help pay for a wide range of medical,
prescription, dental and vision expenses.
The money in this account is yours and rolls over from year to year. You can save it or
use it for qualified expenses now or anytime in the future. It’s also portable, so if you
retire or leave 99 Cents Only Stores, you can take it with you.
The HSA is paired with our Premier Care Lifestyle HSA plan.
✓ Contributions are pre-tax and are automatically deducted
✓ Funds roll over from year-to-year and are yours to keep
✓ Catch-up contributions are for those aged 55 and older
PayFlex
An FSA saves you money by reducing your income taxes. You must choose how much to contribute
each year, up to the stated limit. Your FSA contributions are automatically deducted from
your pay BEFORE any taxes are calculated, and are not reported as income to the IRS.
The FSA
plan is effective January 1 to December 31 (calendar year). Funds do not roll over from year
to year. Any unused funds at the end of year will be forfeited. Existing employees may
enroll
during Open Enrollment. New hires must fulfill their eligibility requirements prior to
enrolling.
✓ Contributions are pre-tax and are automatically deducted
✓ Funds do not roll over from year to year
PayFlex
With this coverage, you can deliver peace of mind to your family in the event of your unexpected death.
✓ Receive up to 2x your annual salary up to a maximum of $250,000
✓ Living Benefit allows you to collect 80% of your policy while living in the event you are diagnosed with a terminal illness
✓ You may be able to keep coverage if you leave the company, retire, or change the number of hours you work
If you’re suddenly unable to earn a paycheck due to illness or an accident, short term disability insurance through your employer can replace a portion of your income during the initial weeks of your disability.
✓ Receive a portion of your salary for 26 weeks
✓ Off-the-job coverage
Long-term disability insurance through your employer can provide a steady stream of income to help cover essential expenses during an extended illness or after a disabling accident.
✓ Offers additional coverage beyond your initial Short-term disability coverage
MetLife
Provides financial protection in the event of your or a dependent’s death, to help cover costs such as funeral expenses, daily expenses, and more.
✓ Get additional coverage for you, your spouse and/or dependents
✓ Is in addition to your company-provided Life and AD&PL plan
Provides cash payments in the event of an accident, with two levels of coverage to choose from.
✓ Pays benefits directly to you
✓ Family options available
✓ Payroll-deducted premiums
Provides a cash payment of $1,000 (once per calendar year) if you are hospitalized, and $150 per day for a maximum of 31 days per hospital stay.
✓ No lifetime maximum
✓ No waiting period
✓ Benefits paid directly to the insured
Critical illness pays a tax-free lump sum if you’re diagnosed with a covered critical illness. Choose a benefit amount up to $30,000. A cash benefit is payable to you at time of diagnosis of a covered critical illness and is paid regardless of any other coverage.
✓ No lifetime maximum
✓ No waiting period
✓ Benefits paid directly to you
Provides you additional coverage above-and-beyond your company-paid short-term disability coverage, supplementing an additional benefit of up to 60% of your income if you live in AZ, NV, TX or WA (up to 30% in CA) and are faced with an unexpected sickness or off-the-job injury.
✓ Financial Protection for up to 60% of your salary (30% in CA)
✓ Elimination period and monthly benefits that fit your needs
✓ Waiver of premium for total disability
Legal assistance for the most needed personal legal matters. There are no copays or deductibles to pay and no claim forms to complete when you use a Network Attorney.
✓ Nationwide network of more than 2,500 law firms
✓ Get help with things like wills, trusts, bankruptcy,
and more
Buying a Home →
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Starting a Family →
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99 Cents Only permits INSURERS to offer employees of 99 Cents Only certain voluntary insurance programs. Whether you choose to enroll in any of these programs is completely optional and voluntary. 99 Cents Only does not make a contribution towards the cost of these programs and employees pay the full cost of premiums on an after-tax basis. 99 Cents Only does not sponsor, maintain, endorse, recommend, or promote these voluntary programs. 99 Cents Only's involvement regarding these voluntary insurance programs is strictly limited to allowing the insurer access to employees to publicize these programs and 99 Cents Only may perform certain ministerial functions such as payroll deduction and forwarding employee premium payments to the insurer. 99 Cents Only 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.
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.
Transamerica
MetLife
Get immediate access to specialized professionals in counseling, social work, human services, and psychology. You have access to the LifeWorks network of thousands of master’s level counselors and affiliates.
✓ Get support with financial and legal issues
✓ Receive 5 free appointments included in your 99 Cents Only benefits
✓ Enjoy hassle-free scheduling with LifeWorks' easy-to-use app
LifeWorks