benefits guide 2015-2016

Transcription

BENEFITS
BENEFITS GUIDE
GUIDE
2015-2016
2013–2014
INTRODUCTION
Dear fellow employees:
Thank you for being a part of the Forever 21 family and for contributing to our success.
Your health and well-being is very important to us and, as such, we are committed to providing
a comprehensive benefits program that will help you and your family members live a happy and
healthy lifestyle.
We are pleased to present the 2015-2016 Forever 21 Benefits Guide to help you navigate your
options for the year and select the best plan for you and your family members.
Please review this Benefits Guide carefully and save this as a reference throughout the year.
Should you require further assistance, do not hesitate to contact the Human Resources Benefits
Department at (213) 741-8897.
Sincerely,
Alex Ok
President
General Disclaimer
The material provided in this guide is for general information purposes only. The details of the plans and policies are
contained in the official plan and policy documents including some insurance contracts. The plan (and underlying
coverage of benefits) can be amended at any time for any reason without prior notice, at Forever 21’s sole and absolute
discretion. In the event of any conflict between this guide and the plan document, the actual plan document will govern.
TABLE OF CONTENTS
How to Enroll ..........................................................................................................................3
Smart Savings .........................................................................................................................4
Eligibility........................................................................................................................................5
Important Notes About Enrollment .......................................................................6
Medical Coverage ........................................................................................................7-9
Dental Coverage................................................................................................................ 10
Vision Coverage....................................................................................................................11
Flexible Spending Account (FSA)..........................................................................12
Commuter Parking and Transit.................................................................................13
Term Life Insurance............................................................................................................14
Group Accident...................................................................................................................15
Whole Life.................................................................................................................................16
Group Critical Illness.........................................................................................................17
Individual Short Term Disability ............................................................................... 18
Group Hospital Indemnity............................................................................................19
Wellness Programs..................................................................................................20-21
Rally..............................................................................................................................................22
401(k).........................................................................................................................................23
Education.................................................................................................................................24
Discount Programs.................................................................................................25-26
Annual Legal Notices............................................................................................27-29
Notes.........................................................................................................................................30
Contacts.....................................................................................................................................31
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be healthy • be happy
HOW TO ENROLL
You have two options to enroll.
Option 1: To speak to a counselor, please contact the enrollment center at (877) 331-8719.
Option 2: To enroll through the online Enrollment Portal, please follow the steps below.
BENEFICIOCENTRADO
BENEFITFOCUS
COMO A INICIAR SESIÓN
Siga estos pasos para abrir su pagina de beneficios.
2015-2016 Plan Year
3
SMART SAVINGS
Health care continues to be one of the major costs confronting families each
year. By using the following simple strategies, you can significantly reduce your
health care costs now and in the future . . .
•Copayments for medical services can cost up to $30 per visit.
Take advantage of $0 copayments for preventive and well-baby care
under all medical plans.
•Each visit to an emergency room can cost you up to a $250 copayment.
By visiting an urgent care facility instead of an emergency room, your
copayment can be significantly reduced.
•Smoking is one of the leading causes of many costly health related
problems.
Take advantage of our smoking cessation programs and also encourage
covered family members who smoke to enroll. (UnitedHealthcare and Kaiser
Permanente members only.) Both carriers approve CHANTIX. Ask your doctor
today for a prescription.
•Not all conditions require a doctor’s visit. Call the 24/7 nurse line to
talk to a qualified nurse anytime, day or night.
o UnitedHealthcare members can call (800) 846-4678.
oKaiser Permanente members can call the Nurse Triage Center Advice
line at (888) 576-6225.
• Prescription medication can be expensive and subject to high deductibles.
You can save money on prescriptions by opting for the generic
prescription. Ask your doctor to prescribe generic drugs when possible.
You can save even more when you purchase your prescriptions through
mail order.
•Employees are required to pay a portion of their earnings for various taxes
such as income and social security.
Save valuable tax dollars by using a Flexible Savings Account (FSA) to set
aside pre-tax earnings to pay for everyday eligible health care expenses
for you and your eligible dependents. You may also set aside pre-tax earnings
to pay for dependent care, commuter parking and transit expenses. (See
pages 12 and 13 for more details.)
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ELIGIBILITY
Employee Eligibility
Dependent Eligibility
• Are a full-time employee, and
• Have met the required waiting period (30 days)
• Part time employees – benefits contingent on each 12
• Your legal spouse
• Your same-sex registered domestic partner
• Your child(ren), the child(ren) of your legal spouse or
registered same-sex domestic partner, until age 26
You are eligible to participate in Forever 21’s Benefit Plans
if you:
Forever 21 provides valuable benefits for your dependents.
Your eligible dependents are:
month period of service (excluding Hawaii and Puerto Rico)
Upon meeting the eligibility requirements, your benefits will
become effective the first day of the following month (unless
you are hired on the first of the month)
Benefit
Eligibility
Waiting Period
Who Qualifies
Medical, Dental, Vision, and Voluntary Benefits (Flexible
Spending Accounts, Buy-Up Term Life Insurance, Whole Life
Insurance, Individual Short Term Disability, Group Accident,
Group Critical Illness and Group Hospital Indemnity)
30 days
All full-time employees
Part-time employees who have met
eligibility
401(k)
Full-time (21 years of age
and 3 months of service)
Part-time (21 years of
age, 12 months of service
and 1,000 hours worked)
All employees
(full-time and part-time)
Paid Time Off (PTO)
After 3 months of service
(available as time is accrued)
Varies on position
Paid Time Off (PTO)
After 6 months of service
(available as time is accrued)
Varies on position
Paid Holidays: Easter, Memorial Day, Independence Day,
Labor Day, Thanksgiving Day, Christmas Day, New Years Day
Upon hire date
Varies on position
Paid Bereavement Leave
Upon hire date
All full-time employees
UNPAID Family and Medical Leave (FMLA)
Employed for 12 months
(with at least 1,250 hours
worked)
All employees
UNPAID Pregnancy Leave (State Specific Laws Apply)
Varies
All employees
UNPAID Personal Leave
30 days
All employees
Educational Discounts
Upon hire date
All employees
10% Employee Discount
Upon hire date
All employees
Cell Phone Discount through AT&T and Verizon
Upon hire date
All employees
Working Advantage and Dell Product Discounts
Upon hire date
All employees
24-Hour Fitness
Upon hire date
All employees
Pet Insurance
Upon hire date
All employees
2015-2016 Plan Year
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IMPORTANT NOTES ABOUT ENROLLMENT
What if I have questions, comments or concerns?
The Human Resource Benefits Department is available to assist you. You can
contact the Human Resource Benefits Department by phone at (213) 741-8897
or via e-mail at HR.Benefits@forever21.com.
If you experience any of the following life status changes
after enrolling...
The following changes can be made within 30 days of the event date…
You get married or form a registered same-sex domestic
partnership
• Add your new spouse or partner and/or stepchild(ren) to your
medical, dental, or vision plans
•E
nroll in or increase your contributions to a Health Care or
Dependent Care FSA
•A
pply for Supplemental Life insurance for your new spouse or
partner
If your situation involves a domestic partner, you may want to
contact a qualified tax advisor due to the tax treatment of domestic
partner benefits
You get divorced, have an annulment, become legally
separated, or end your domestic partnership
•R
emove your former spouse or partner from Forever 21 coverage
(required)
• Decrease your contributions to a Health Care FSA
You experience the birth, or adoption of a child
• Add your new child to your plans
•E
nroll in or increase your contributions to a Health Care or
Dependent Care FSA
• Apply for Supplemental Life insurance for your new child
Your spouse, domestic partner, or child dies
• Remove your dependent from Forever 21’s coverage (required)
•D
ecrease your contributions to a Health Care or Dependent
Care FSA
If you have Supplemental Life Insurance coverage for that
individual, be sure to file a claim for benefits
Your child reaches the maximum age (26) for coverage or is
no longer totally disabled
Remove your child from Forever 21’s coverage (required)
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MEDICAL COVERAGE
Medical coverage is one of the most important components of your benefit package. Forever 21 offers a range of medical options
to fit your needs and budget.
What’s the difference between an EPO and
a PPO?
HMO
Terms to help you understand your coverage:
Kaiser operates as a Health Maintenance Organization (HMO).
You must choose a primary care physician who will manage your
healthcare and refer you to specialists and testing as necessary.
Most services are covered 100% by your insurance after your
copayments. Note that Kaiser Permanente is offered for California
employees only.
EPO
An Exclusive Provider Organization (EPO) offers comprehensive
health services as long as you choose doctors (including specialists),
hospitals, and pharmacies in the Choice network. If you receive care
outside of the UnitedHealthcare network, the plan will not cover
the cost. You may visit a specialist or other provider in the network
without a referral.
•Annual Deductible: The amount you must pay each
calendar year before insurance pays any amount..
•Copayment: A payment you must make, usually at the
time of service, in addition to what insurance pays.
•Coinsurance: The percentage that insurance pays after
you have met your deductible.
•Out of Pocket Maximum: The most you are required to
pay in coinsurance in any plan year before insurance
pays 100% of eligible expenses.
PPO
In a Preferred Provider Network (PPO), you can choose to visit any
physician of your choice, without a referral. You are responsible
for all copays and any coinsurance after your annual deductible
up to your annual out-of-pocket maximum. However, costs are
higher for services received outside of the preferred network of
doctors.
Review the following chart for more HMO, EPO and PPO
differences:
Can I go to any doctor I want and
receive plan benefits?
Is there a deductible?
Will I need to choose a Primary
Care Physician?
Do I need a referral to see a
specialist?
Is preventative care (well-child
care, check-ups, etc.) covered?
Is there a limit to how much I may
have to pay in one year?
Are prescription drugs covered?
Can I use mail order for
maintenance drugs?
Will I have to pay more if any
doctor charges more than the
“reasonable and customary” limit?
HMO
EPO
PPO
No, you may only go to doctors
within the Kaiser Permanente
network. You may see a specialist
with a referral.
No
Yes
No, you may only go to doctors
within the UnitedHealthcare
network. You may see a
specialist without a referral.
Yes
No
Yes, but you pay lower costs if
you use doctors and hospitals
in the network.
Yes
No
No
Yes
Yes, covered at 100%
(In Network ONLY)
Yes, refer to your EPO Plan
out of pocket maximum
Yes, covered at 100%
(In Network ONLY)
Yes, refer to your PPO Plan
out of pocket maximum
Yes
Yes, and you will pay less out of
pocket
No
Yes
Yes, and you will pay less out
of pocket
Only when you use
out of network providers
Yes, refer to your Kaiser
Permanente out of pocket
maximum
Yes
Yes, and you will pay less out of
pocket
No
Yes
No
2015-2016 Plan Year
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MEDICAL COVERAGE
Forever 21 employees have five different medical options to choose from, depending on where you live:
• Kaiser Permanente HMO (California only)
• UnitedHealthcare Choice EPO (California only)
• UnitedHealthcare Choice Plus PPO HDHP
• UnitedHealthcare Choice Plus PPO Low
• UnitedHealthcare Choice Plus PPO High
EPO/HMO COMPARISON CHART (CALIFORNIA ONLY)
Benefit and Covered Services
Employee Premium Contributions
Employee only
Employee + spouse
Employee + child(ren)
Employee + family
Annual Deductible
Coinsurance
Maximum Out of Pocket
Lifetime Maximum Benefit
Physician Office Visit
Urgent Care
Inpatient Hospital
Emergency Room
Generic Prescription Drugs
Brand Name Prescription Drugs
Non Preferred Brand Prescription Drugs
Specialty
Kaiser Permanente HMO Plan
(Per Paycheck)*
UnitedHealthcare Choice EPO Plan
(Per Paycheck)
$41.54
$83.08
$78.46
$124.62
None
$48.53
$96.83
$92.85
$143.70
$500 individual
$1,000 family
90%
$2,000 individual
$4,000 family
None
$30 copay per visit
$30 copay per visit
90% after deductible plus $500 copay per admission
90% after $200 copay per visit
$15 copay
$35 copay
$50 copay
20% up to a $100 copay
100%
$1,500 individual
$3,000 family
None
$25 copay per visit
$25 copay per visit
$500 copay per admission
$100 copay per visit
$15 copay up to 30 days
$30 copay up to 30 days
*Forever 21 supports registered same-sex domestic partner coverage in all states. Please contact the HR Benefits Department for more
information. Domestic partnership is processed on a post-tax basis. Imputed income will apply.
*Required Grandfathered Plans Status Disclosure
Forever 21, Inc. believes the medical plans are “grandfathered
health plans” under the Patient Protection and Affordable Care Act
(the Affordable Care Act). As permitted by the Affordable Care Act, a
grandfathered health plan can preserve certain basic health coverage that
was already in effect when that law was enacted. Being in a grandfathered
health plan means that your medical plan may not include certain
consumer protections of the Affordable Care Act that apply to other
plans. However, grandfathered health plans must comply with certain
other consumer protections in the Affordable Care Act, for example, the
elimination of lifetime limits on benefits.
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Questions regarding which protections apply and which protections do
not apply to a grandfathered health plan and what might cause a plan to
change from grandfathered health plan status can be directed to the plan
administrator at (213) 741-8897.
You may also contact the Employee Benefits Security Administration, U.S.
Department of Labor at (866) 444-3272 or www.dol.gov/ebsa/healthreform.
This website has a table summarizing which protections do and do not
apply to grandfathered health plans.
MEDICAL COVERAGE
PPO COMPARISON CHART (ALL STATES)
Benefit and Covered
Services
UHC Choice Plus PPO HDHP UHC Choice Plus PPO Low
(Per Paycheck)
(Per Paycheck)
UHC Choice Plus PPO High
(Per Paycheck)
$30.35
$60.77
$57.73
$90.00
In Network
$3,000 individual
$6,000 family
$42.35
$84.50
$81.03
$125.40
Out of Network In Network
$6,000 individual $2,000 individual
$12,000 family
$4,000 2 persons
$6,000 family
Out of Network
$4,000 individual
$8,000 2 persons
$12,000 family
$65.00
$129.69
$124.36
$192.47
In Network
$1,000 individual
$2,000 2 persons
$3,000 family
Out of Network
$2,000 individual
$4,000 2 persons
$6,000 family
Coinsurance
Maximum Out of Pocket
70%
$6,000 individual
$12,000 family
50%
$12,000
individual
$24,000 family
70%
$5,000 individual
$10,000 2 persons
$15,000 family
50%
$8,000 individual
$16,000 2 persons
$24,000 family
80%
$4,000 individual
$8,000 2 persons
$12,000 family
60%
$8,000 individual
$16,000 2 persons
$24,000 family
Lifetime Maximum Benefit
Physician Office Visit
Unlimited
$25
Unlimited
50%
Unlimited
Unlimited
$25 copay per visit 50%
Unlimited
60%
Urgent Care
$125 copay per
visit
70%
50%
$25 copay per visit 50%
50%
$250 copay
$15 copay
$35 copay
$60 copay
70% after $250
50%
copay per day up
to 3 days
70% after $100 copay per visit
$15 copay
$35 copay
$60 copay
Unlimited
$20 copay per
visit
$20 copay per
visit
80%
80%
$10 copay
$35 copay
$60 copay
80%
30% up to a $150 copayment
Employee only
Employee + spouse
Employee + family
Annual Deductible
Inpatient Hospital
Emergency Room
Generic Prescription Drugs
Brand Name Prescription Drugs
Non Preferred Brand Prescription
Drugs
Specialty
60%
60%
*Forever 21 supports registered same-sex domestic partner coverage in all states. Please contact the HR Benefits Department for more
information. Domestic partnership is processed on a post-tax basis. Imputed income will apply.
Go to page 19 and consider Group Hospital Indemnity Insurance. This plan helps provide funds
toward co-insurance, copays and deductibles when you are admitted with a hospital stay.
Stay Active to Stay Healthy
Fitness is for everyone, and best of all, it includes every kind of exercise. As long as you do it regularly, any physical activity
can help you look and feel your best. Whether you’re 5 or 65, it’s never too early or too late to get started. Just keep these tips
in mind:
•You don’t have to sweat it. Research shows that getting at least 2 hours and 30 minutes of moderate-intensity activity can
make a significant difference in your health. You can get the same benefits by working a little harder for a shorter time.
•Find the right fit. The key to getting regular exercise is to choose activities that you enjoy and feel comfortable doing so
that you’ll want to keep doing them.
•Three’s company. Aerobic exercise, strength training, and flexibility are all key components of total fitness.
•Mix it up. Are you already active and looking for a new routine? Or maybe you want to optimize your health and fitness
level? Consider cross-training to help you reach your goal.
2015-2016 Plan Year
9
DENTAL COVERAGE
Aetna Dental® Freedom of Choice – More Savings, More Choices
With Two Dental Networks
You have the freedom to switch dental plans monthlyChoice #1: The Dental Maintenance Organization (DMO®) Plan
Key Highlights
• Lower out of pocket costs than the PPO
• A Primary Care Dentist (PCD) coordinates your care
• Get a referral to see a specialist, except for orthodontia
• Typically, no cost for preventive care
• No deductible or annual benefit maximum
• Enhanced orthodontia
• Can switch to the PPO plan each month, if you prefe
Choice #2: The Preferred Provider Organization (PPO) Plan
Key Highlights
• Generally, higher out of pocket costs than the DMO
• Visit any licensed dentist
• Use network dentists for discounts to stretch your benefit
• Can switch to the DMO plan each month, if you prefer
• No referrals
• Annual benefits maximums apply
Aetna Dental® Freedom of Choice
Choose between these two plan options monthly (Per Paycheck)
Aetna DMO®
Benefit & Covered Services
Employee only
Employee + 1 dependent
Employee + 2 or more dependents
Diagnostic & Preventative – Exams,
cleanings, x-rays, sealants
Basic – Fillings, simple tooth
extractions, root canals, gum
treatment & oral surgery
Major – Crowns, inlays, onlays, cast
restorations, bridges & dentures
implants
Calendar Year Deductibles
Aetna PPO®
In Network
In Network
Out of Network
$6.15
$11.06
$18.40
100%
Exam $5 copay
100%
$6.15
$11.06
$18.40
100%
$6.15
$11.06
$18.40
50%
70%
50%
60%
50%
50%
None
$50 Individual
$150 Family
$100 Individual
$300 Family
Deductible Exempt on Diagnostic
and Preventive
Calendar Year Maximum
N/A
Yes
Yes
None
$1,500
$1,500
Orthodontic for Adult & Children
100% after $2,300 copay for
Adult and Child
24 months
50%
50%
$1,500
$1,500
Orthodontic Lifetime Maximum
You can switch between the Aetna DMO and the Aetna PPO monthly, if desired, by calling Aetna at 855-850-9664 by the 15th of the month, for the change
to be effective the 1st of the next month. There are three ways to find a participating dentist: 1) Online at www.aetna.com 2) By phone after you enroll
you can call Member Services at the toll-free number on your Aetna ID card 3) Download the Aetna mobile app to your smartphone.
To learn more about Aetna Dental’s Freedom of Choice Plan click on www.aetnafocdental.com
*DMO is not offered in the following states: AL, AK, AR, LA, ME, MS, ND, NH, PR, SC
*Forever 21 supports registered same-sex domestic partner coverage in all states. Please contact the HR Benefits Department for more information.
Domestic partnership is processed on a post-tax basis. Imputed income will apply.
10
VISION COVERAGE
How the Vision Plan Works
You have two VSP Vision plans to choose from: Premium and Core. Your Vision plan choice will depend on whether you are
also enrolled in a Forever 21 Medical plan and whether you want to pay more from each paycheck for the richer benefits of the
Premium Plan.
If you enroll in any Medical plan
with Forever 21, you are eligible to
be enrolled in the VSP Core Vision
Plan at NO COST to you.
If you enroll in a Medical plan with
Forever 21, BUT want the benefits of a
richer vision plan, you can elect to pay
an additional amount each paycheck
for the VSP Premium Plan.
VSP Core Vision (per paycheck)
If you do not enroll
in a Medical plan
$1.45
$2.90
$3.10
$4.96
If you enroll in a
Medical plan*
No Cost
No Cost
No Cost
No Cost
Employee only
Employee + spouse
Employee + family
Core Coverage
Benefit &
Covered
Services
If you DO NOT enroll in a Medical plan
with Forever 21, but still want a vision
plan, you can elect to enroll in either
the VSP Core Plan or the VSP
Premium Plan.
VSP Premium Vision (per paycheck)
If you do not enroll
in a Medical plan
$3.18
$6.35
$6.79
$10.86
If you enroll in a
Medical plan
$1.98
$3.96
$4.25
$6.78
Premium Coverage
Description
Copay
Description
Copay
$10
•F
ocuses on your eyes and overall
wellness
• Every 12 months
$10
Prescription Glasses
$25
Prescription Glasses
$25
Frame
Included in
•$
175 allowance for a wide selection of
Prescription
frames
Glasses
• $95 allowance at Costco
• 20% off amount over your allowance
• Every 12 months
Included in
•S
ingle vision, lined bifocal, and lined
Prescription
trifocal lenses
Glasses
•P
olycarbonate lenses for dependent
children
• Every 12 months
$0
• UV Protection
$55
• Scratch-resistant coating
$95 - $105
• Standard progressive lenses
$150 - $175 • Premium progressive lenses
• Custom progressive lenses
• Average 20 – 25% off other lens options
$0
• $175 allowance for contacts and contact
lens exam (fitting and evaluation)
•1
5% off contact lens exam (fitting and
evaluation)
• Every 12 months
WellVision
Exam®
• Focuses on your eyes and overall
wellness
• Every 12 months
• $130 allowance for a wide selection of
frames
• $70 allowance at Costco
• 20% off amount over your allowance
• Every 24 months
Lenses
• Single vision, lined bifocal, and lined
trifocal lenses
• Polycarbonate lenses for dependent
children
• Every 24 months
Lens Options • Scratch-resistant coating
• Standard progressive lenses
• Premium progressive lenses
• Custom progressive lenses
• Average 20 – 25% off other lens options
Contacts
(instead of
glasses)
• $130 allowance for contacts and
contact lens exam (fitting and
evaluation)
• 15% off contact lens exam (fitting and
evaluation)
• Every 24 months
Included in
Prescription
Glasses
Included in
Prescription
Glasses
$0
$0
$55
$95 - $105
$150 - $175
$0
Contact lenses are in lieu of lenses and frame.
*There is no employee premium contribution for the VSP Core plan if you are also enrolled in a Forever 21 medical plan.
*Forever 21 supports registered same-sex domestic partner coverage in all states. Please contact the HR Benefits Department for more information.
Domestic partnership is processed on a post-tax basis. Imputed income will apply.
2015-2016 Plan Year
11
FLEXIBLE SPENDING ACCOUNTS (FSA)
You have the option of contributing pre-tax dollars to a Health
Care Flexible Spending Account and/or a Dependent Care
Flexible Spending Account. By setting aside pre-tax dollars
from your paycheck, you are reducing your taxable income and
can therefore save money by reducing the amount of income
tax you owe. You must re-enroll annually in these plans in
order to participate for the next calendar year.
For detailed information on qualifying FSA expenses, visit
www.padmin.com (visitors). FSA operates on a calendar year,
January 1, 2016 - December 31, 2016.
Health Care FSA
The Health Care FSA allows you to set aside pre-tax earnings
to pay for everyday eligible health care expenses for you and
your eligible dependents. You can contribute between $100
and $2,550 each plan year to pay for qualifying out-of-pocket
medical, dental, vision, and prescription drug expenses.
Examples of eligible expenses include:
• Co-payments, coinsurance & deductibles
• Charges for services or supplies not covered by your
medical, dental, or vision plan
• Charges above the usual, customary and reasonable rates
or plan maximums.
Examples of ineligible expenses include:
ROLLOVER FEATURE:
You may rollover
a remaining balance between $100 to $500 for your
Health Care FSA to the following calendar year.
• Cosmetic surgery
• Botox
• Restylane
• Over-the-counter drugs unless prescribed by a physician
Dependent Care FSA
THINGS TO THINK ABOUT
• Your FSA elections will remain fixed for
the entire plan year. However, if your
family status changes, you may be able to
increase or decrease your contributions to
these accounts.
• Funds cannot be transferred between
your Health Care and Dependent Care
accounts.
• Generally the IRS does not consider a
Domestic Partner as a qualified relative,
so they (and their expenses) may not be
claimed under the FSA plans, unless they
qualify as dependents on your Federal
income tax return.
FSA REMINDER: You must re-enroll annually
in your FSA plan in order to participate for the next
calendar year.
PLEASE NOTE: The IRS dependent care limit is
$5,000 per year as a combined family limit.
12
The Dependent Care FSA allows you to set aside pre-tax
earnings to pay for a wide range of dependent care services
for eligible members of your family. You can contribute
between $100 and $5,000 each plan year to reimburse
yourself for qualified dependent care expenses.
Examples of eligible expenses include:
• Senior day care
• Child day care
• In-home dependent care
• Private preschool program
• Nursery school
• Before and after-school programs
• Sick child care
Eligible dependents include:
• A child under age 13 in your custody whom you claim as a
dependent on your tax return
• A spouse who is incapable of self-care
• A dependent who lives with you, such as a child over age 13,
parent, sibling, or in-law who is incapable of self-care, and
whom you claim as a dependent on your tax return
Examples of ineligible expenses:
• School expenses for children in first grade or above
• Food or clothing provided for your dependent
• Care provided by your spouse, your child under age 19, or
someone you claim as a dependent for tax purposes
• Overnight camp expenses
• Transportation expenses to and from the care location
• Babysitting for social events
COMMUTER PARKING AND TRANSIT
Want to save 30% on your
monthly parking or transit
expenses for work?
Enroll in the Parking/Transit Account and use taxfree
dollars to offset your cost of commuting to and
from work! Estimate the money you expect to pay
for parking or transit and have that dollar amount
withheld from your paychecks pre-tax each month.
Here’s An Example Of How
The Tax Savings Works
Commuting expenses are inevitable for you
because you travel to work almost every day. Let’s
assume you spend $100.00 per month for parking
at work or commuting to and from work. By
enrolling in the Parking/Transit Account, $100 will
be withheld from your paychecks over a monthlong
period pre-tax, so you never have to pay the
state, federal and FICA taxes on your parking of
transit expenses! If you fall within the average 30%
tax bracket, enrolling in this account will save you
approximately $30 every month! That’s an annual
savings of $360!
Parking/Transit Account Rules
There are maximum amounts you can elect for this plan. The below
amounts are based on the IRS pre-set maximum for the year 2015-2016.
• Maximum pre-tax monthly parking contribution: $255
• Maximum pre-tax monthly transit contribution: $255
P&A Benefits Card
If you enroll in this plan you will receive a debit card
that can be used to pay for your parking/transportation
expenses to and from work. Employees who enroll in
both the FSA and Parking/Transit Account will receive
one debit card for both accounts. If you are currently
enrolled in the FSA and enroll in the Parking/Transit
Account, your election amount will be automatically
added to your current debit card.
If your parking garage or mass transportation
system does not accept debit cards you can file a
claim with P&A Group to receive reimbursement
for your expense. Claims can be submitted using
one of the three claim submission options.
The Parking/Transit Plan offers flexibility. Unlike the FSA Plan, with the
Parking/Transit Account you can change your election amount each
month. Please note that any change you make will become effective with
the first pay period beginning on or after the following month. So, for
example, let’s say you have a vacation and will not be commuting to work.
You can change your election amount for that month by notifying your
HR department. You will be asked to fill out a new election form for that
month.
Claim Submission Methods
• Electronic Claim Upload: Upload claims directly at www.padmin.com.
Log into your P&A account - Member Tools - Upload a Claim. When
using this method you MUST provide a copy of your receipt in order to
process the claim. If you do not have a copy of your receipt please click
on the Un-receipt Claim System, which will direct you to our online
claim system for parking/transportation expenses that do not have
receipts.
• Fax: (877) 855-7105*
• Mail: 17 Court Street, Suite 500 Buffalo, NY 14202*
*Must include a claim form. Claims forms are located here: Log into your
P&A Account - Forms - Claim Form.
2015-2016 Plan Year
13
GROUP BENEFIT: VOLUNTARY TERM LIFE (Unum)
Buy-Up Group Term Life Insurance
Employee: Additional one or two times your annual earnings up to $500,000. Employee Guarantee Issue: $200,000. Any Life
Insurance coverage over the Guarantee Issue amount will be subject to evidence of insurability.
Spouse/Domestic Partner: You can choose to purchase coverage for your spouse in amounts of $10,000, $25,000, $50,000 or
$100,000, not to exceed 100% of employee coverage amount.
Child: You can choose to purchase coverage for your child(ren) in amounts of $5,000 or $10,000. The maximum death benefit for a
child between the ages of live birth and 6 months is $1,000. Benefits will be paid to the employee.
In order to purchase Life Insurance coverage for your spouse and/or child, you must purchase coverage for yourself.
Accelerated benefit - If you become terminally ill and are not expected to live more than 12 months, you may request up to 50%
of your life insurance amount, to a maximum of $750,000 or the plan maximum, whichever is less, without fees or
present value adjustments. A doctor must certify your condition. Upon your death, any remaining benefit will be paid to your
designated beneficiaries.
Effective Date of Coverage:
Your coverage will become effective the first day of the month following 30 days of service.
Delayed Effective Date of Coverage:
Employee: Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary
layoff, or leave of absence on the date that insurance would otherwise become effective.
Dependent: Insurance coverage will be delayed if that dependent is totally disabled on the date that insurance would otherwise
be effective. Exception: infants are insured from live birth. “Totally disabled” means that, as a result of an injury, a sickness or a
disorder, your dependent is confined in a hospital or similar institution; is unable to perform two or more activities of daily living
(ADLs) because of a physical or mental incapacity resulting from an injury or a sickness; is cognitively impaired; or has a life
threatening condition.
The policy has exclusions and limitations which may affect any benefits payable. See the actual policy or your Unum
Representative for specific provisions and details of availability.
Group Term Life Insurance is underwritten by: Unum Life Insurance Company of America, Portland, Maine
© 2015 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring
subsidiaries.
CE-14095 (7-15)
14
VOLUNTARY BENEFITS: GROUP ACCIDENT (Unum)
Forever 21 is excited to offer a number of voluntary benefits to ensure you and your family have the support and resources when
you need them most. Our voluntary benefits are unique in that they are not tied to us as an employer. So, if you ever leave the
Forever 21 family, and we hope you don’t, you can take these benefits with you.
Hearing the word “oops” is never a
good thing.
Maybe your spouse fell off the ladder while cleaning the
gutters, or your child tripped and broke a tooth playing
outside, or you threw your back out cleaning the garage.
Unexpected accidents always have lousy timing, especially
when you are responsible for insurance deductibles and outof-pocket costs. You need a plan that helps you protect your
family and your wallet. Voluntary accident insurance from
Unum can help with this:
• Hospitalization deductibles and copays
• Doctor visit copays
• Visits to the emergency department
• Physical therapy
• Transportation and lodging
Features you’ll appreciate
Accident insurance can help cover the extra costs that can
occur when you, your spouse, or your children suffer a
covered injury – like those that can happen during a game of
pick-up basketball or when your kids go rollerblading. It also
covers on-the-job accidents.
• No health questions to answer – You will automatically receive the base plan if you apply.
• Lump sum benefit – You will receive a predefined benefit
based on the injury or qualifying event.
• Family coverage:
o Employees who are actively at work are eligible. Spouses
age 17 to 64 who are actively at work or not disabled.
• Dependent children newborn until their 26th birthday.
• A Catastrophic Benefit* is included with this plan. This pays
an additional sum if a covered individual has a serious
injury – such as loss of sight, hearing, or a limb.
Additional coverage options
• Your employer has selected the optional Sickness Hospital
Confinement Benefit. If chosen, this benefit could pay
you or your spouse a $100 daily benefit if hospitalized due
to a covered illness. Children receive 75% of the employee
amount.
Other important information
• Premiums are automatically deducted from your paycheck.
• Coverage becomes effective on the first day of the month in
which payroll deductions begin.
• This plan may be portable should you leave the company or
retire.
The policy has exclusions and limitations which may affect
any benefits payable. See the actual policy or your Unum
representative for specific provisions and details of availability.
THIS IS A LIMITED POLICY.
Employees must be legally authorized to work in the U.S. and
actively working at a U.S. location. Spouses and dependents
must live in the U.S. to receive coverage.
Group accident insurance is underwritten by:
Unum Life Insurance Company of America, Portland, Maine
© 2015 Unum Group. All rights reserved. Unum is a registered trademark
and marketing brand of Unum Group and its insuring subsidiaries.
CE-14095 (7-15)
*365 day elimination period applies
2015-2016 Plan Year
15
VOLUNTARY BENEFITS: WHOLE LIFE (Unum)
Why consider interest-sensitive whole life? Interest-sensitive whole life insurance can provide an additional source of financial
protection for your working years and provide options for your retirement.
Plan Features
•Policy can build cash value based on the guaranteed interest
rate of 4.5%.
• Interest-sensitive whole life insurance premiums do not
increase as you get older.
• The death benefit (the policy’s face value) remains constant
and does not decrease as you get older. The death benefit
can only be reduced if there is a policy debt.
• If you are actively at work* for a minimum of 30 hours
per week, you can sign up during Forever 21’s enrollment
period and apply for insurance without taking a health exam.
However, you may be asked a few health questions.
• If you choose, you can use the accumulated cash value to
buy a smaller “paid-up” policy with no more premiums due,
or cash in the policy at any time.
• You own the policy and can take it with you if you leave the
company or retire.
*Eligible employees must be actively at work to apply for coverage. Being
“actively at work” means that on the day you apply for coverage, you are
working at one of your company’s business locations, or you are working
at a location where you are required to represent your company. If you are
applying for coverage on a day that is not one of your scheduled workdays,
then you will be considered actively at work if you meet this definition as
of your last scheduled workday. You are not considered actively at work if
your normal duties are limited or altered due to your health, or if you are
on a leave of absence.
±Limited life expectancy of 24 months in IL, MA and WA.
Additional features
• Living Benefit Option Rider – automatically included at no
extra charge on all policies. You can request up to 100%
of the death benefit (to a maximum of $150,000) if you are
diagnosed with a medical condition that limits life
expectancy to 12 months± or less. Any payout reduces the
death benefit.
• Accidental Death Benefit Rider – pays an extra benefit
equal to the base policy amount (subject to a $150,000
maximum) if the policy holder dies before age 70 as the
result of a covered accident. Payout is doubled if insured
dies as a result of a covered accident while a fare-paying
passenger via commercial transportation. Death benefit
will increase by 25% if death occurs while wearing a seat
belt while driving or riding in a non-commercial automobile.
• Wavier of premium – an additional benefit included in this
policy, if you become disabled prior to age 65 and remain
disabled for at least six months, premiums paid during the
six month waiting period are refunded and will be waived as
long as you remain disabled. Available to employees age 15
to 55.
Family Coverage options
• This insurance is available for your spouse, based on a
qualifying health question, even if you don’t apply for your
own policy.
• Coverage is available for your children, stepchildren, legally
adopted children, grandchildren age 14 days through 24
years. Whole life is available as a standalone policy, or a
children’s term rider* can be attached to your policy – or
your spouse’s policy – if you are less than 65 years old.
*not available in WA
Unum offers whole life insurance as a Guarantee Issue,
depending on your eligibility. Guarantee Issue means you can
enroll without answering any health questions or taking any
physical exams.
• Existing employees who have purchased this product in
previous enrollments: Guarantee Issue – no qualifying
health questions up to a certain amount of coverage
•Newly Eligible employees receive guaranteed issue up to a
certain amount of coverage. Late entrants must first answer
health questions
A Typical Interest-Sensitive Whole Life Benefit Example:
The Situation
• A new mother wants to supplement her life coverage with
a policy that offers:
• Guaranteed premiums
• A cash accumulation feature
• Is portable
• She is also interested in:
• Coverage for her husband and son
• Needs help finding good coverage at an affordable rate
The Solution
• She purchases:
• A $25,000 policy for herself
• A separate $25,000 policy for her husband; no health
exam needed
• A term rider for her son; can be converted to an
individual policy without a health exam to ensure he
always has access to life insurance
•H
er policy cash value accumulates at a guaranteed interest
rate of 4.5% and can be used to buy a reduced paid-up policy
without any additional premiums
The policy may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. See the actual
policy or your Unum representative for specific provisions and details of availability.
Whole Life Insurance is underwritten by: Provident Life and Accident Insurance Company, Chattanooga, Tennessee
In New York, underwritten by: First Unum Life Insurance Company, New York, New York
© 2015 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.
Employees must be U.S. or Canadian citizens, or have a green card, to receive coverage. Spouses and dependents must live in the U.S. to receive
coverage.
CE-14095
16
VOLUNTARY BENEFITS: GROUP CRITICAL ILLNESS (Unum)
Could your bank account survive a serious illness?
Be prepared with group critical illness insurance from Unum.
Critical illness insurance can pay a lump sum benefit at
the diagnosis of a covered illness. You choose the level of
coverage with benefit amounts from $5,000 to $50,000. You
can use the money to pay for copays, deductibles, childcare,
transportation, lodging, or any other expenses that you
may have.
What is covered?
The following specified critical illnesses are covered under the
base plan:
• Heart attack
•Blindness
•Major organ failure
• End-stage renal (kidney) failure
• Coronary artery bypass surgery (pays 25% of lump
sum benefit)
• Benign brain tumor
• Stroke (evidence of persistent neurological deficits
confirmed at least 30 days after the event)
• Coma (resulting from severe injury lasting for 14
consecutive days or more)
• Permanent paralysis (complete and permanent loss of the
use of two or more limbs for a continuous 90 days as a
result of a covered accident)
You may also choose to select this benefit for an additional
premium for the following specific critical illnesses:
• Cancer
•Carcinoma in situ1 (pays 25% of the lump sum benefit)
Please refer to the policy for complete details about these
covered conditions.
You can use this coverage more than once. If you receive a
full benefit payout for a covered illness, your coverage can be
continued for the remaining covered conditions. The diagnosis
of a new covered illness must occur at least 90 days after the
most recent diagnosis. Each condition is payable once per
lifetime.
The following is automatically included in your plan:
Wellness benefit
This benefit can pay $75 per calendar year per insured
individual if a covered health screening test* is performed,
including:
• Blood tests
• Stress tests
•Colonoscopies
• Chest X-rays
*A full list of covered tests will be provided in your certificate.
CE-14095
Who is eligible?
• All employees who are actively at work
• Spouse ages 17 through 64
• Dependent children (newborn until their 26th birthday)
All eligible children are automatically covered at 25% of
the employee benefit amount at no additional cost. Eligible
children are covered for the same conditions as the employee
and the following specific childhood conditions: cerebral
palsy, cleft lip or palate, cystic fibrosis, Down syndrome and
spina bifida. Diagnosis must occur after the child’s coverage
effective date.
Policy provisions
Waiting period – Diagnosis must occur at least 30 days after
the coverage effective date to be eligible for benefits (Wellness
Benefit does not apply to coma, and permanent paralysis or
the specific childhood conditions listed above).
Pre-existing condition limitation – Unum will not pay benefits
for a claim that is caused by, contributed to by or occurs as a
result of a pre-existing condition. Please refer to information
provided in your certificate or consult with your benefits
representative to determine what would be considered a
pre-existing condition.
Coverage effective date
12 months before
effective date
12 months after
effective date
pre-existing limitation does
not apply
Reduction of benefits – The benefit amount for the employee
and spouse reduces by 50% on the first policy anniversary date
after the insured individual’s 70th birthday. Premiums will
not be reduced. For coverage purchased after age 70, benefit
amounts will not be reduced.
Being “actively at work” means you are working for your employer for
earnings that are paid regularly and that you are performing the material
and substantial duties of your regular occupation. You must be working at
least the minimum number of hours as described under Minimum Hours
Requirement shown in the Benefits at a Glance. Your work site must be: Your Employer’s usual place of business; - an alternative work site at the
direction of Your Employer; or - a location to which Your job requires You
to travel.
Carcinoma in situ is defined as cancer that involves only cells in the
tissue in which it began and that has not spread to nearby tissues.
1
This information is not intended to be a complete description of the
insurance coverage available. The policy or its provisions may vary or
be unavailable in some states. The policy has exclusions and limitations
which may affect any benefits payable. For complete details of coverage
and availability, please refer to Policy Form: CI-1 or contact your Unum
representative.
In CA, insured individuals must be covered by comprehensive health
coverage before applying for group critical illness insurance.
In CA, occupational HIV is not a covered condition.
In CA, $200 mammography benefit is included within the base plan
is payable based on a pre-defined schedule – please review the policy
for details.
THIS INSURANCE PROVIDES LIMITED BENEFITS.
Group Critical Illness Insurance is underwritten by: Unum Life Insurance
Company of America, Portland, Maine
© 2015 Unum Group. All rights reserved. Unum is a registered trademark
2015-2016 Plan Year
17
VOLUNTARY BENEFITS: INDIVIDUAL SHORT TERM DISABILITY
Disability insurance protects a portion of your salary during
a covered disability. Unum individual short term disability
insurance replaces a portion of your income if you are unable
to work due to a covered injury or sickness. This means
you can have some income during a time of need. Common
reasons people use this coverage include pregnancy, injuries
and digestive problems – such as gall bladder surgery.
Advantages of the plan
• Choose a monthly benefit from $400 to $5,000 for an
illness or off-the-job injury. Coverage up to 60% of your
gross monthly salary may be offered (max of 40% in CA, HI,
NJ, NY and RI)
• Affordable coverage. Your premiums are based on your age
when you buy the insurance and will not increase as you
get older+.
• Available to eligible employees 17-69 (64 in CA and NY) who
are actively at work.
• Premiums are conveniently deducted from your paycheck.
• You own the policy. If you leave or retire, you can take
your policy with you and pay the same premium. Unum will
bill you directly at home.
+Premiums can be changed only if we change them on all policies of this
kind in force in the state in which the policy is issued.
Policy provisions
Pre-existing condition limitation— If you have a pre-existing
condition* within a 12-month1 period before your coverage
effective date, benefits will not be paid for a disability period if
it begins during the first 12 months2 the policy is enforced.
*A pre-existing condition is a condition for which symptoms existed (within
12 months before your coverage effective date) that would cause a person
to seek treatment from a physician or for which a person was treated or
received medical advice from a physician, or took prescribed medicine.
The determination on whether your condition qualifies as pre-existing will
be based on the date of disability and not the date you notify Unum.
Pregnancy3— Nine months after coverage becomes effective,
pregnancy is considered the same as any other covered
illness. The available monthly benefits will be paid upon
fulfillment of the elimination period. Benefits will not be paid if
the insured individual gives birth within nine months after the
coverage becomes effective. However, medical complications
of pregnancy may be considered as any other covered
sickness, subject to the pre-existing condition limitation.
1 Six-month period applies in ID and NV.
2 Six-month period in TX (for applicants 65+).
3 Nine-month giving-birth exclusion is not applicable in KS, MT and OK.
This policy provides disability income insurance only. It does NOT provide
basic hospital, basic medical or major medical insurance as defined by
New York State Department of Financial Services. The expected benefit
ratio for this policy is 50%. This ratio is the portion of future premiums
which the company expects to return as benefits, when averaged over all
people with this policy.
18
(Unum)
This information is not intended to be a complete description of the
insurance coverage available. The policy or its provisions may vary or
be unavailable in some states. The policy has exclusions and limitations
which may affect any benefits payable. For complete details of coverage
and availability, please refer to Policy Form: L-21776 (FUL-21841 for NY)
(L-21820-CA) and contact your Unum representative. Unum complies with
all state civil union and domestic partner laws when applicable.
Individual Short Term Disability Insurance is underwritten by:
Provident Life and Accident Insurance Company
Chattanooga, Tennessee
In New York, underwritten by:
First Unum Life Insurance Company
New York, New York
Employees must be U.S. or Canadian citizens, or have a green card,
to receive coverage. Spouses and dependents must live in the U.S. to
receive coverage.
unum.com
©2015 Unum Group. All rights reserved. Unum is a registered trademark
CE-14095
VOLUNTARY BENEFITS: GROUP HOSPITAL INDEMNITY
Unum’s Group Hospital Indemnity Insurance can complement
your medical insurance to help you pay for the costs
associated with a hospital stay. It can also provide funds for
the out of pocket expenses your medical plan may not cover,
such as co-insurance, co-pays and deductibles.
How does it work?
This insurance pays a benefit when you are admitted* to the
hospital for a covered accident or sickness.
*Covered individuals must be hospitalized for at least 20
hours.
You may receive a benefit for the following:
•$2,000 for a covered hospital admission, once per calendar
year
•$100 each day of your covered hospital stay, up to 15 days
per calendar year
Advantages of the plan
•Coverage is available to all eligible employees who are
actively at work.*
•You can buy coverage for your spouse and dependent
children.
•This plan includes convenient payroll deduction, so you don’t
have to remember to write a check for your premiums.
•Coverage is portable. You may take the coverage with you
if you leave the company or retire without having to answer
new health questions. Unum will bill you directly.
•Coverage becomes effective on the first day of the month in
which payroll deductions begin.
Policy provisions
Benefits for a pre-existing condition (defined as a sickness or
injury, diagnosed or treated, for which you received medical
treatment, care or services, including diagnostic measures,
took prescribed drugs or medicine, or had been prescribed
drugs or medicine to be taken during the 12 months just prior
to your effective date) will not be paid if the date of the covered
loss occurs during the first 12 months after your effective
date.
(Unum)
*Eligible employees must be actively at work to apply for
coverage. Being actively at work means on the day the
employee applies for coverage, the individual must be
working at one of his/her company’s business locations, or
the individual must be working at a location where he/she is
required to represent the company. If applying for coverage
on a day that is not a scheduled workday, the employee will
be considered actively at work as of his/her last scheduled
workday. Employees are not considered actively at work if they
are on a leave of absence.
Employees must be legally authorized to work in the U.S. and
actively working at a U.S. location. Spouses and dependents
must live in the U.S. to receive coverage.
This information is not intended to be a complete description
of the insurance coverage available. The policy or its
provisions may vary or be unavailable in some states. The
policy has exclusions and limitations which may affect any
benefits payable. For complete details of coverage and
availability, please refer to policy form GHI-1, or contact your
Unum representative.
THIS IS A LIMITED POLICY
This coverage is a supplement to health insurance. It is not a
substitute for comprehensive health insurance and does not
qualify as minimum essential health coverage.
Underwritten by: Unum Life Insurance Company of America,
Portland, Maine
Unum complies with state civil union and domestic partner
laws when applicable.
unum.com
©2015 Unum Group. All rights reserved. Unum is a registered
trademark and marketing brand of Unum Group and its
insuring subsidiaries.
CE-14095 (7-15)
Employees, spouses and dependent children must have
comprehensive medical coverage before purchasing hospital
indemnity insurance.
2015-2016 Plan Year
19
WELLNESS PROGRAMS
(You must be actively enrolled in a UnitedHealthcare or Kaiser Permanente Health Plan to participate, the Chantix program is not
automatically guaranteed or required.)
Tobacco Cessation Program
UnitedHealthcare’s tobacco cessation program is tailored to
your individual smoking habits and needs. You’ll set a “Quit
Date” and begin a staged approach to stop smoking. This
program features five levels with tips on how to quit smoking,
cessation information, and access to additional interactive
tools to help keep you on track to meet your Quit Date goal.
To access this program, log on to www.myuhc.com, click
‘Health&Wellness,’ then ‘Your Personal Health Center’ on the
right side of the screen.
Chantix: Helps Make Quitting Count!
Have you been looking for a method to help you quit
smoking? Chantix, a new prescription drug, is now
covered by both Kaiser Permanente and UnitedHealthcare
(EPO & PPO). What’s really great is that both carriers
offer a free support program, because it’s always easier
with a little extra help.
Kaiser Permanente offers: HealthMedia® Breathe
(More details can be found at www.kp.org/healthylifestyles)
UnitedHealthcare offers: Smoking Cessation Plan
(More details can be found at www.myuhc.com)
Baby on the way?
If so, UnitedHealthcare has a program just for you.
A healthy pregnancy helps ensure a healthy mom and
baby. The Maternity Support Program offers you and your
dependents health and educational support from the time
you consider starting or expanding your family, through the
first few months of your new baby’s life. This free, confidential
program is offered to you as part of your regular benefit
package. To get the most from the program, it’s best to enroll
during the first trimester of your pregnancy. To enroll call
877-201-5328.
With UnitedHealthcare’s Neonatal Resource Services
Program, parents can get the education and support they need
during this stressful time that may help avoid readmissions
and post-discharge complications. UnitedHealthcare’s
dedicated team of NICU nurse case managers, social workers,
and medical directors collaborate in monitoring the clinical
care and other services, including psychological, provided to
the baby and parents.
20
Source4Women
Source4Women gives you answers to your health and
wellness questions, in plain language. From interactive
seminars and presentations to healthy recipes and tips from
the experts, we give you information to help you make more
informed decisions. You’ll find information about health plan
options, terms, and benefits, as well as resources to help
you evaluate your options when selecting a plan. And you
can access easy-to-use tools that let you take control of your
care. Whether you’re preparing for a doctor visit or need
help filling prescriptions, you’ll find answers you can trust at
Source4Women.com.
Discount Programs
UnitedHealthcare’s discount program helps you and your
family save typically 10 to 25 percent on many health and
wellness purchases not included in your standard health
benefit plan.
Use the plan for:
• Weight management from Jenny Craig®1, Nutrisystem®
and other popular programs
• Nutrition counseling
• Fitness clubs including Anytime Fitness®, Bally Total
FitnessSM, Curves®, Gold’s Gym®, Jazzercise®, MyGym®
and Snap Fitness™
• Fitness equipment and apparel
• Natural products and foods
• Stress reduction and relaxation
WELLNESS PROGRAMS
You must be actively enrolled in a Kaiser Permanente Health Plan to participate. Available to CA residents only.
Challenge Yourself To Stay Healthy
Kaiser Permanente can provide the resources to help.
If you’re feeling good now, health care coverage might be
the furthest thing from your mind. Sure, you can just pay for
emergency care if you get sick or injured, but can you get the
resources to help you stay strong and healthy for the long run?
With Kaiser Permanente, you can.
More than just health care
If you’ve got them, use them. Take advantage of the tools you
need to help you stay well and keep tackling new challenges.
• My Health Manager. E-mail your doctor’s office, order
prescription refills, and more at kp.org/myhealthmanager.*
• Preferred rates on specialty health services. Get massage
therapy, acupuncture, and fitness club memberships for less
at kp.org/choosehealthy.†
• Farmers’ markets. Check out locations and schedules at
kp.org/farmersmarket.
• Hear here. Download podcasts of our audio programs at
kp.org/listen.
• Healthy living classes. Find health-related programs,
groups, and classes near you at kp.org/classes. (Some
classes may require a fee.)
• Preventive care. Dealing with health issues early,
before they develop, can save you money. Look up
preventive care tips at kp.org/prevention.
• We’re here for you. If you don’t feel well, call your
doctor during regular office hours or speak to an advice
nurse after hours by calling toll free (800) 576-6225.
• Things happen. We offer after-hours urgent care and
extended hours at many of our locations. And you’re always
covered for emergency care, anywhere in the world. For
questions or concerns, our Member Service Call Center is
available weekdays from 7 a.m. to 7 p.m. and weekends from
7 a.m. to 3 p.m. at (800) 464-4000. (For TTY for the hearing/
speech impaired, call (800) 777-1370.)
There’s no need to go without coverage simply because you
feel fine today. When you tap into everything we have to offer
that’s right for your family, you’ll see that you’ve got more than
just a health care plan—you’ve got a plan for good health.
* To use these secure features for the first time, go to kp.org/register,
then sign on with your user ID and password.
† These products and services are provided by entities other than
Kaiser Permanente. Some Kaiser Permanente benefit plans include
coverage for certain of these discounted services. Plan benefits must
be used before those discounted services are available. Check your
Evidence of Coverage for details. Kaiser Permanente disclaims any
liability for these discounted products and services. Should a problem
arise, you may take advantage of the Kaiser Permanente grievance process
by calling the Member Service Call Center at (800) 464-4000.
2015-2016 Plan Year
21
RALLY
22
401(K) PLAN
2015-2016 Plan Year
23
EDUCATION
University of Phoenix
HOW DO YOU SEE
YOUR FUTURE?
If you’ve been wondering how you could get your
bachelor’s or master’s—or even your doctoral degree—
and still work part time or full time, University of Phoenix
is designed especially for the busy working learner, like
yourself. University of Phoenix offers convenient class
times and flexible scheduling, allowing you to attend class
when most convenient.
Forever 21 has teamed up with University of Phoenix to
bring you special educational benefits and access to an
innovative way to learn. With this opportunity you can
pursue your educational goals while staying on top of your
professional commitments. You may also be able to turn
prior professional development training or certificates into
college credit through Prior Learning Assessment. Learn
more at phoenix.edu/forever21 or call 866.354.1800.
24
DISCOUNT PROGRAMS
2015-2016 Plan Year
25
DISCOUNT PROGRAMS
WORKING ADVANTAGE
Register for your FREE account today! Follow the four
steps below.
Exclusive discounts include:
•
•
•
Entertainment
Theatre and Events
Shopping and Gifts
WORKING ADVANTAGE
STEP 2
STEP 3
STEP 4
STEP 1
Go to www.workingadvantage.com/Forever21
Select the Register button at the top of the page
Select Employees Click Here
Enter Member ID# 561188160
DELL DISCOUNTS
Save on the latest Dell products & select electronics and
accessories
NATIONAL AT&T WIRELESS
DISCOUNTS
Forever 21 Employees are eligible to receive DISCOUNTS for
their New and Existing Personal Wireless Service with AT&T!
The discount for Monthly Recurring Service Charges is 18%.
This is applied to your primary voice plan of $39.99 or higher,
and Wireless Phone Data plans that are $25 and higher
(Unlimited and Unity Plans are not eligible).
Shop or Register For Your Discount Online:
att.com/wireless/FOREVER21
To Register:
Step 1: Go to the website and type in your zip code and
click Continue.
Step 2: Look for the “discount registration” link at the top of
the page, then click on it and follow the steps!
Website is also available for new orders and upgrades.
Equipment pricing and promotions found on this website are
“exclusive” to this site. No other AT&T Channel will “support”
or “match” equipment promotions available on this site!
Phone – For Ordering Only:
National Business Ordering (888) 444-4410
Company Sponsorship GSM FAN #2415530
Your membership benefits include:
•
•
•
Best price on Dell consumer PCs
Free membership to the Dell Advantage loyalty program
Discounts on electronics and accessories
Shop Dell using your membership:
Dell.com/mpp/
or 1-888-243-9964
Member ID: GS22938926
VERIZON DISCOUNTS
Save 15% on your monthly calling or data plan, phone &
accessories!
What you have to do:
•
•
•
•
26
Visit verizonwireless.com/discounts
Enter work email address and select “Check for discounts”
You will receive an email. Click the “Get Started” button in the email
to continue registering
Click on the “Register Your Line” link in the “Existing Customers”
section under “Enroll”. If you do not have a work email, click on the
“I do not have a work email address” link and follow the prompts.
Retail Store:
Sponsorship program is available in AT&T retail stores.
Equipment pricing will vary compared to the sponsorship
website. Please check with your retail sales rep if Premier
pricing applies. Bring a paycheck stub or ID badge! To find a
store near you visit: www.att.com/storelocator.
For assistance, please refer to all inquiries regarding your
personal service with AT&T to the Premier site ‘help’ tab,
your AT&T retail store, or by calling (800) 331-0500.
Please note the following disclaimers for National AT&T
Wireless Discounts:
• While AT&T is a valued corporate partner of Forever 21, this should
not be interpreted as a sole endorsement for your personal use. You
have many choices when you choose a wireless provider, and should
you choose AT&T, we have made an employee discount available to
you.
• The relationship you establish with AT&T is not tied to our corporate
partnership with them, except for the discount available. You are
financially liable for all payments and guarantees, and Forever 21
has no part in that relationship.
• Forever 21 has no part in the escalation or distribution of information
regarding cellular use on a personal basis, but is simply forwarding
this information to you as a courtesy. Please refer all inquiries
regarding your personal service with AT&T to the Premier site, a
retail store, or by calling (800) 331-0500.
ANNUAL LEGAL NOTICES
The following Forever 21 health plan notices summarize
important information about the health plans offered to
eligible employees. Please share this information with
your family members and refer to the more comprehensive
benefit materials for further detail. In the event of a conflict
between this information and the carrier’s contracts and
agreements, the terms of the official plan documents will
govern.
Coordination of Benefits
Your medical and dental options contain a coordination of
benefits provision that is designed to prevent the duplication
of coverage and overpayment of benefits when you or your
eligible dependents are covered by more than one plan. Here
is how coordination of benefits works:
• If you are the patient, the Forever 21 Plan will pay benefits
first. The other plan will pay benefits according to its own
coordination of benefits rule after you submit a claim.
• If your spouse is the patient and has coverage through
another plan, his or her plan will pay benefits first. The
Forever 21 Plan will pay its normal benefits minus any
benefits paid by the first plan. This means that your spouse
will not receive any benefit from the Forever 21 Plan if your
spouse’s plan pays benefits that are equal to or greater than
the benefits Forever 21 would pay.
• If your child is the patient and he or she is covered by the
Forever 21 Plan and your spouse’s plan, the decision about
which plan pays first is covered by the “birthday rule”: This
means that the Forever 21 Plan pays first if your birthday
(month/day) comes before your spouse’s in the calendar
year. For example, if your birthday is March 1 and your
spouse’s is April, Forever 21 benefits pay first. Otherwise,
your spouse’s plan pays first. If the Forever 21 Plan pays
second, it will reduce its normal benefit by the amount paid
by the other plan.
Continuing Coverage through
COBRA
The Consolidated Omnibus Budget Reconciliation Act (COBRA)
allows you to temporarily extend you and your dependents’
medical, dental and vision benefits and Health Care FSA in
certain situations where coverage would other wise end (for
example, at your termination of employment). If you elect
COBRA coverage, your medical, dental, and vision benefits
will continue for a defined period of time. Your spouse and
dependent children can also continue coverage under COBRA.
You will be required to pay the premiums for this continued
coverage, which will be the full cost of the plan plus a 2%
administrative fee. For more information about continuing
coverage through COBRA, please contact the HR Benefits
Department at 213-741-8897.
Privacy Rights Under HIPAA
The Health Insurance Portability and Accountability Act of 1996
(HIPAA), requires that health plans protect the confidentiality
of your private health information. This Plan, the Plan
Administrator, and the Plan Sponsor will not use or disclose
information that is protected by HIPAA (protected health
information) except as necessary for treatment, payment,
and other health care operations of the Plan, or as permitted
or required by law. In particular, the Plan will not, without
authorization, use or disclose protected health Information for
employment-related actions and decisions, or in connection
with any other benefit or employee benefit plan of your
Employer. The Plan also requires all of its business associates
(as that term is defined by HIPAA) to observe HIPAA’s privacy
requirements.
Protected health information may be used by and disclosed
to Human Resources and Benefits and Finance/Accounting
employees of your Employer who are responsible for carrying
out administrative functions for the Plan (such as enrollment/
disenrollment, determinations of eligibility and benefits due,
provider payments, participant reimbursements, and audits).
However, these employees will only have access to the
information on a “need to know” basis and will use only
the minimum necessary protected health information to
accomplish the intended Plan administration purposes.
Special Enrollment Rights Under
HIPAA
If you are declining enrollment for yourself or your dependents
(including your spouse) because of other health insurance
coverage, you may be able to enroll yourself or your
dependents in this plan in the future, provided that you request
enrollment within 30 days after your other coverage ends.
If you have a new dependent as a result of marriage, birth,
adoption, or placement for adoption, you may be able to enroll
yourself and your dependents, provided that you request
enrollment within 30 days after the marriage, birth, adoption
or placement for adoption.
2015-2016 Plan Year
27
Women’s Health and Cancer Rights
Act
The Women’s Health and Cancer Rights Act of 1998 requires
that all health insurance plans that cover mastectomy also
cover the following medical care:
• Reconstruction of the breast on which the mastectomy was
performed.
• Surgery and reconstruction of the other breast to produce
symmetrical appearance.
• Treatment of physical complications in all stages of
mastectomy, including lymphedema.
• Mastectomy bras and external prostheses limited to the
lowest cost alternative available that meets the patient’s
physical needs.
If you have questions about your benefits under the medical
plans, please call the member services number on your
medical ID card or contact the HR Benefits Department at 213741-8897..
Newborns’ and Mothers’ Health
Protection Act
The Newborns’ and Mothers’ Health Protection Act of 1996
prohibits the plan from limiting a mother’s or newborn’s length
of hospital stay to less than 48 hours for a normal delivery or
96 hours for a Cesarean delivery or from requiring the provider
to obtain preauthorization for a stay of 48 or 96 hours, as
appropriate. However, federal law generally does not prohibit
the attending provider, after consultation with the mother, from
discharging the mother or her newborn earlier than 48 hours
for normal delivery or 96 hours for Cesarean delivery.
Mental Health Parity
The Mental Health Parity and Addiction Equity Act of 2008
requires plans to provide mental health and substance abuse
benefits at the same level that benefits for medical and
surgical related benefits are offered. Key changes that will
affect most group health plans include:
• Group health plans are prohibited from having annual
lifetime maximum dollar limits for mental health benefits
that are less than medical or surgical benefits.
• The new law expands mental health benefits to include
substance use disorder benefits.
• Cost-sharing provisions, such as deductibles and copays, or
a plan’s terms regarding the amount, duration, and scope
of mental health benefit s are no longer restricted from the
plan.
28
Summary of Benefits and Coverage
(SBC)
As required by law, across the US, insurance companies and
group health plans like ours are providing plan participants
with a consumer-friendly SBC as a way to help understand
and compare medical benefits. Each SBC contains concise
medical plan information, in plain language, about benefits and
coverage, including: what is covered, what you need to pay for
various benefits, what is not covered and where to go for more
information or to get answers to questions. SBC documents
are updated when there is a change to the benefits information
displayed on an SBC.
Government regulations are very specific about the information
that can and cannot be included in each SBC. Plans are not
allowed to customize very much of the SBC documents. There
are detailed instructions the Plan had to follow about how the
SBCs look, how many pages the SBC should be (maximum of
4 pages), the font size, the colors used when printing the SBC,
and even which words were to be bold.
The SBC for our medical plans are available to you at
www.myforever21benefits.com, BenefitFocus
(https://forever21.hrintouch.com) or by contacting the HR
Benefits Department at 213-741-8897.
Important Notice About Your
Prescription Drug Coverage and
Medicare
Notice of Creditable Coverage
This Notice applies only if you and/or your dependent(s) are
enrolled in a Forever 21 medical plan and you are eligible for
Medicare. If this does not apply to you, you may ignore this notice.
Please read this notice carefully and keep it where you can find
it. This notice has information about your current prescription
drug coverage with Forever 21 and about your options under
Medicare’s prescription drug coverage. This information can
help you decide whether or not you want to join a Medicare
drug plan. If you are considering joining, you should compare
your current coverage, including which drugs are covered at
what cost, with the coverage and costs of the plans offering
Medicare prescription drug coverage in your area. Information
about where you can get help to make decisions about your
prescription drug coverage is at the end of this notice.
There are two important things you need to know about your
current coverage and Medicare’s prescription drug coverage:
1. M
edicare prescription drug coverage became available in
2006 to everyone with Medicare. You can get this coverage
if you join a Medicare Prescription Drug Plan or join a
Medicare Advantage Plan (like an HMO or PPO) that offers
prescription drug coverage. All Medicare drug plans provide
at least a standard level of coverage set by Medicare. Some
plans may also offer more coverage for a higher monthly
premium.
2. F
orever 21 has determined that the prescription drug
coverage offered under Forever 21 plans are, on average
for all plan participants, expected to pay out as much as
standard Medicare prescription drug coverage pays and is
therefore considered Creditable Coverage. Because your
existing coverage is Creditable Coverage, you can keep this
coverage and not pay a higher premium (a penalty) if you
later decide to join a Medicare drug plan.
When Can You Join A Medicare
Drug Plan?
You can join a Medicare drug plan when you first become
eligible for Medicare and each year from October 15th to
December 7th. However, if you lose your current creditable
prescription drug coverage, through no fault of your own, you
will also be eligible for a two (2) month Special Enrollment
Period (SEP) to join a Medicare drug plan.
What Happens To Your Current
Coverage If You Decide to Join A
Medicare Drug Plan?
If you decide to join a Medicare drug plan, your current Forever
21 coverage will not be affected. The Creditable Plans will pay
primary to Medicare.
If you do decide to join a Medicare drug plan and drop your
current coverage, be aware that you and your dependents will
only be able to re-enroll in our medical benefits during our
Annual Open Enrollment or if you have a qualifying event.
When Will You Pay A Higher
Premium (Penalty) To Join A
Medicare Drug Plan?
You should also know that if you drop or lose your current
coverage with Forever 21 and don’t join a Medicare drug plan
within 63 continuous days after your current coverage ends,
you may pay a higher premium (a penalty) to join a Medicare
drug plan later.
If you go 63 continuous days or longer without creditable
prescription drug coverage, your monthly premium may go up
by at least 1% of the Medicare base beneficiary premium per
month for every month that you did not have that coverage.
For example, if you go nineteen months without creditable
coverage, your premium may consistently be at least 19%
higher than the Medicare base beneficiary premium. You may
have to pay this higher premium (a penalty) as long as you have
Medicare prescription drug coverage. In addition, you may have
to wait until the following October to join.
For More Information About This Notice Or Your Current
Prescription Drug Coverage…
Contact the person listed below for further information.
NOTE:You’ll get this notice each year. You will also get it before
the next period you can join a Medicare drug plan, and if this
coverage changes. You also may request a copy of this notice at
any time.
For More Information About Your Options Under Medicare
Prescription Drug Coverage…
More detailed information about Medicare plans that offer
prescription drug coverage is in the “Medicare & You”
handbook. You’ll get a copy of the handbook in the mail every
year from Medicare. You may also be contacted directly by
Medicare drug plans.
For more information about Medicare prescription drug
coverage:
•V
isit www.medicare.gov
•C
all your State Health Insurance Assistance Program (see
the inside back cover of your copy of the “Medicare & You”
handbook for their telephone number) for personalized help
•C
all 1-800-MEDICARE (1-800-633-4227). TTY users should
call 1-877-486-2048.
If you have limited income and resources, extra help paying
for Medicare prescription drug coverage is available. For
information about this extra help, visit Social Security on the
web at www.socialsecurity.gov, or call them at 1-800-772-1213
(TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide
to join one of the Medicare drug plans, you may be required to
provide a copy of this notice when you join to show whether or not
you have maintained creditable coverage and, therefore, whether
or not you are required to pay a higher premium (a penalty).
Date: August 3, 2015
Name of Entity/Sender: Forever 21
Contact--Position/Office: HR Benefits Department
Address: 3880 N. Mission Road, #3120
Los Angeles, CA 90031
Phone Number: 213-741-8897
2015-2016 Plan Year
29
NOTES
CONTACTS
Benefit Plans
Medical Plans
Contact Information
UnitedHealthcare Choice EPO (California only)
UnitedHealthcare Choice Plus PPO HDHP
UnitedHealthcare Choice Plus PPO Low
UnitedHealthcare Choice Plus PPO High
Policy #755321
(888) 510-9416 (Customer Service)
www.myuhc.com
Dental Plans
Vision Plan
Kaiser Permanente HMO (California only)
• Southern California Group # 231108
• Northern California Group # 603668
(800) 464-4000 (Member Services)
www.kp.org
Aetna
(855) 850-9664
www.aetnanavigator.com
VSP
(800) 877-7195 (Member Services)
www.vsp.com
Voluntary Plans
Flexible Spending Accounts
P&A
(800) 688-2611
www.padmin.com
Whole Life Insurance, Individual Short Term
Disability, Group Accident, Group Critical
Illness and Group Hospital Indemnity
Unum
(800) 635-5597
www.unum.com
Buy-Up Term Life Insurance
Unum
(800) 445-0402
www.unum.com
Information and Enrollment
Forever 21 Contacts
Phone: (213) 741-8897
Fax: (213) 743-0560
HR.benefits@forever21.com
Forever 21 Benefits Portal
www.MyForever21Benefits.com
This Employee Benefits Brochure highlights the main features of your benefit programs and does not include all the rules and details, including limitations and exclusions. The terms
of your benefit plans are governed by legal documents, including insurance contracts and the Summary Plan Description. If there is a conflict between the information in this brochure
and the formal language of the Summary Plan Description (SPD), the wording in the Summary Plan Description (SPD) will govern.
2015-2016 Plan Year
31
be healthy.
be happy.
32

benefits guide 2015-2016

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