Employee Benefits

About Your Benefits 2016–2017
URBN Urban Outfitters, Inc.
Enroll online at portal.adp.com
To Enroll
Make Your Life Insurance Elections
Make Your Health Benefit Elections
After reviewing your options, consider how much
money your family would need to cover your financial
obligations if something should happen to you. Also, take
a moment to designate your beneficiary(ies) for both your
Basic Group Life/AD&D Insurance and Voluntary Life
Insurance. You will automatically be the beneficiary for
your spouse and child(ren).
Review your Medical, Dental and Vision plan options in
this booklet. Carefully consider which plans best meet
your needs and which dependent family members you wish
to cover.
Verify Your Dependents
If you are adding dependents to your plans, you will need to
enter your dependent information online at
portal.adp.com. You will then receive a letter and list of
required documentation in the mail. Please follow the
instructions outlined in the documents.
An eligible dependent is defined as:
If you elect to purchase Voluntary Life Insurance after
your initial eligibility period or if you are currently enrolled
in Voluntary Life Insurance and increase your purchase
amount during open enrollment, you may be required to
complete and submit a Statement of Health form.
• A legal spouse
Submit Your Benefit Elections
You will submit your benefit elections online at
portal.adp.com. Click the USER Sign In Button and enter
your user name and password. If you are new to the system,
click on First Time User Create Account, then enter
Registration code:
and click Go and
follow the prompts. Next, select the benefits tab drop down
and choose Welcome. Click on the benefits website link.
• A child up to age 26 regardless of student status, marital status, financial dependence or residence
•
Any age mentally or physically disabled child (who became disabled prior to age 26)
Make Your FSA Elections
Consider the pre-tax benefits associated with using
an FSA to pay for expenses not covered by insurance.
Carefully decide what amount, if any, you will elect to be
deposited into your FSA. Remember, you may not change
this election during the plan year.
To complete the online enrollment process, be sure to
click on “FINISH” after you have elected your benefits.
Your benefit elections will not be saved if you fail to click
“FINISH.” Also, you should print a copy of your online
elections for your records. Once your elections are
processed, a benefits confirmation statement will be sent
to your address on file.
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Medical
Medical Questions?
Contact Independence Blue Cross at 1-800-ASK-Blue
or visit ibx.com
MEDICAL BENEFITS
You may choose between the following two medical plans administered by Independence Blue Cross:
Option 1: Base Plan
The Base Plan offers the same type of care as the Core Plan, but you will generally pay more out-of-pocket for the same covered medical services. As a result, the payroll deduction is lower than the Core Plan.
Option 2: Core Plan
The Core Plan provides a richer level of coverage in-network, lower copays and a lower out-of-network deductible when compared to the Base Plan. However, the payroll deduction is higher than the Base Plan.
Benefit Description
Base Plan
Core Plan
In-Network
Out-Of-Network
In-Network
Out-Of-Network
Individual: $0
Family: $0
Individual: $2,500
Family: $5,000
Individual: $0
Family: $0
Individual: $500
Family: $1,000
Individual: $2,500
Family: $5,000
Individual: $10,000
Family: $20,000
Individual: $1,000
Family: $2,000
Individual: $3,000
Family: $6,000
Primary Care Visits
$20 copay
50%*
$15 copay
50%*
Specialist Visits
$40 copay
50%*
$30 copay
50%*
Hospital (Inpatient & Outpatient)
75%
50%*
90%
50%*
Emergency Room
$100 copay (waived if admitted)
Annual Deductible
Out-of-Pocket Maximum
$100 copay (waived if admitted)
*Services are subject to deductible and UCR.
IMPORTANT PL AN NOTES:
• Out-of-network providers may bill you for the difference between the plan allowance (also known as “UCR” or “Usual, Customary and Reasonable” fee) and the provider’s actual charge. This amount may be significant. It is important to note that all percentages for out-of-network services are percentages of UCR, not the provider’s actual charge.
• The information contained within this summary includes any current changes to our benefit plans. You may also find an outline of current plan changes by accessing the “Summary
of Material Modifications (SMM)” document in the Library section of portal.adp.com.
Summary of Benefits and Coverage (SBC)
SBCs are documents that detail your medical/prescription benefits. You may view and/or print a copy by visiting the Plan Information/Common Forms &
Plan Information section of portal.adp.com.
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Need a doctor?
Contact MDLIVE at 1-877-764-6605
or visit mdlive.com/ibx
Telemedicine
MDLIVE
MDLIVE provides you and your dependents with 24/7/365 access to remote medical care for common, acute conditions by
phone or online. Your board-certified, state-licensed MDLIVE physician can diagnose a variety of conditions, recommend
treatment and even prescribe medication as needed.
The telemedicine benefit will provide you with convenient access to care at a very low cost. Your copay for each visit is $10,
which is less than your primary care copay and much less than your emergency room copay. Round-the-clock access to the
benefit may save you time and money. The ability to speak to a doctor on the phone or on video through a webcam means that
you can address a number of conditions without taking time out of your busy schedule to sit and wait in a doctor’s office. Since
the MDLIVE network includes pediatricians, you can access care when your child wakes up in the middle of the night with a
fever and your family practitioner’s office is closed, rather than taking them to the ER.
Contacting An MDLIVE Doctor
There are three convenient ways to reach an MDLIVE doctor:
• Speak with a doctor over the phone
• Visit with a doctor through your computer’s webcam over the internet
• Ask questions and get advice privately using secure e-mail
Commonly Treated Conditions Include
General Health
• Acne
• Allergies
• Asthma
• Bronchitis
• Cold & Flu
• Constipation & Diarrhea
• Fever
• Gout
• Headache
• Infections
• Insect Bites
• Joint Aches & Pains
• Nausea & Vomiting
• Pink Eye
• Rashes
• Sinus Infection
• Sore Throat
• Sports Injury
• Sunburn
• Urinary Tract Infection
• Nausea & Vomiting
• Pink Eye
• Mood Swings
• Substance Abuse
• Eating Disorders
• Obsessive Compulsive
Disorder
Pediatric Care
• Cold & Flu
• Constipation & Diarrhea
• Fever
• Ear Infection
Mental Health
• Anxiety & Depression
• Child Behavior Issues
• Post Traumatic Stress
Disorder
• Sleep Disorders
• Marital & Relationship
Issues
• Smoking Addiction
IMPORTANT PL AN NOTES:
• When you enroll in either of the medical plans, you are automatically enrolled in the telemedicine benefit through MDLIVE.
• If you are eligible to receive the telemedicine benefit, a welcome kit from MDLIVE will be mailed to your home address.
• Please note that due to statutory regulations, MDLIVE is not available in Arkansas and only video consultation is allowed (no phone) in Idaho.
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Prescription
Rx questions?
Contact Express Scripts, Inc. at 1-800-818-0093
or visit express-scripts.com
PRESCRIPTION BENEFITS
When you enroll in either of the medical plans, you will receive prescription benefits through Express Scripts, Inc.
Prescription Drugs
Retail
Mail Order
Generic
$10
$25
Preferred
$30
$75
Non-Preferred
$50
$125
Up to 34 days
Up to 90 days
Dispensing Limit
Non-Network Pharmacy
Plan pays 50% of allowable charge
Express Scripts Mail Order Program
You should consider the convenience and savings of having your maintenance drugs (those taken for 3 months or more)
delivered to your home or office through the Express Scripts Mail Order Program. Through this program, you can:
• Receive up to a 3-month supply compared with a 1-month supply at retail of each covered medication for just one Mail Order copay.
• Contact a registered pharmacist 24 hours a day, 7 days a week.
• Order refills online, by mail, or by phone—anytime day or night. To order online, register at express-scripts.com. Refills are usually delivered within 3 to 5 days after your order is received.
Maintenance Drugs
Maintenance drugs, beginning with the 4th refill, must be filled through the Express Scripts mail order program. If you choose to
fill a maintenance drug at a retail pharmacy more than 3 times, you will be charged the Mail Order copay. When you choose the
Express Scripts mail order program, you will receive a 3-month supply at 2.5 times the retail copay, thereby saving you money.
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Dental questions?
Contact MetLife at 1-800-GET-MET8
or visit metlife.com/mybenefits
Dental
DENTAL BENEFITS
You may choose between the following two dental plans administered by MetLife. The group number for both plans is 100762.
Option 1: Dental Plan
The Dental Plan provides coverage for preventive, basic, and major care.
Option 2: Dental Plus Plan
When compared to the Dental Plan, the Dental Plus Plan provides the following enhanced benefits:
• Lower annual deductible
• Higher annual benefit maximum
• Higher level of coverage for both in-network and out-of-network services
• Adult orthodontia benefit and higher orthodontia lifetime maximum
Dental Plan
Benefit Description
Annual Deductible*
Annual Benefit Maximum
Dental Plus Plan
In-Network
Out-of-Network
In-Network
Out-of-Network
Individual: $50
Family: $150
Individual: $100
Family: $300
Individual: $25
Family: $50
Individual: $75
Family: $150
$1,000 per person (combined in - & out-of-network)
$2,500 per person (combined in - & out-of-network)
Type A - Preventive
90%**
80%***
100%**
100%***
Type B - Basic Restorative
80%**
70%***
80%**
80%***
Type C - Major Restorative
50%**
40%***
60%**
60%***
Type D - Orthodontia
Orthodontia Lifetime Maximum
50%**
50%***
Orthodontia only available to children under 19
50%**
50%***
Orthodontia available to children and adults
$1,000 per person (combined in - & out-of-network)
$2,000 per person (combined in - & out-of-network)
* Annual Deductible only applies to Basic and Major Services.
** Refers to the covered percentage of the PDP fee. This is the amount participating network dentists have agreed to accept as payment in full.
*** Refers to the covered percentage of what is considered a Reasonable and Customary (R&C) charge for dentists in that same geographic area.
IMPORTANT PL AN NOTES:
• Texas residents receive the same dental coverage regardless of whether they receive care from a participating or non-participating provider. Texas residents may access their state-specific dental plan information by visiting the Plan Information/Common Forms & Plan Information section of portal.adp.com.
Benefits - What’s Covered?
Type A - Preventive
• Prophylaxis
(cleanings)
• Oral Examinations
• Child Fluoride
Applications
• X-rays
Type B - Basic Restorative
• Sealants
• Space Maintainers
• Fillings
• Simple Extractions
• Crowns/Bridges
• Denture Repair
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Type C - Major Restorative
• Crowns/Inlays/Onlays
• Endodontics
• General Anesthesia
• Oral Surgery
• Periodontics
Vision
Vision questions?
Contact VSP at 1-800-877-7195
or visit vsp.com
VISION BENEFITS
You may choose between the following
two vision plans administered by VSP.
Benefit
Description
Option 1: Vision Plan
Benefits Available
Exam
Lenses
Frames
Contact Lenses
(in lieu of glasses)
The Vision Plan provides coverage for a vision exam
and eyewear.
Option 2: Vision Plus Plan
The Vision Plus Plan provides the following enhanced benefits:
• Increased allowance for frames and contact lenses
• $20 copay for anti-reflective coating
• $20 copay for contact lens exam (in lieu of glasses)
Additional VSP Discounts
Glasses And Sunglasses
20% off additional glasses and sunglasses,
including lens options, from any VSP
provider within 12 months of your last
well-eye exam
Laser Vision Correction
Average of 15% off the regular price or
5% off the promotional price; discounts
are only available from contracted
facilities
Vision Plan
InNetwork
Vision Plus Plan
Out-ofNetwork
InNetwork
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Eye Examination
$45 allowance
See lens
and frame
allowances
below
$20 copay
See lens
and frame
allowances
below
Up to $150
allowance, plus
20% off any
amount over
your allowance
$70 allowance
Up to $250
allowance, plus
20% off any
amount over
your allowance
$70 allowance
Covered in full
Covered in full
Covered in full
$30 allowance
$50 allowance
$65 allowance
Covered in full
Covered in full
Covered in full
$30 allowance
$50 allowance
$65 allowance
Anti-Reflective
Coating
Discount Only
N/A
$20 copay
N/A
Contact Lenses
(in lieu of glasses)
Includes Exam
& Fitting
Up to $150
allowance, plus
15% off contact $105 allowance
exam (fitting &
evaluation)
Up to $250
allowance;
$20 copay
for contact
exam (fitting &
evaluation)
$105 allowance
Frames
Lenses
Single Vision
Lined Bifocal
Lined Trifocal
$45 allowance
$20 copay
Every 12 months
Every 12 months
Every 12 months
Every 12 months
$10 copay
Prescription
Glasses
$10 copay
Out-ofNetwork
IMPORTANT PL AN NOTES:
• Providers in the VSP “Choice” network are considered to be in-network.
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FSA questions?
Contact Payflex at 1-800-284-4885
or visit healthhub.com
Health FSA
HEALTH FLEXIBLE SPENDING ACCOUNT (FSA)
What Is A Health FSA?
Important FSA Dates
A Health FSA allows you to set aside money on a pre-tax basis for health expenses for you and
your dependents.
•
• You may incur claims throughout the plan year, which
runs July 1, 2016 to June 30, 2017.
• You are afforded an additional 90 days from the end
of the plan year (until September 28th) to submit any claims that you have incurred.
Eligible expenses include deductibles, coinsurance, copayments, dental expenses, vision care and hearing care. You may view a full listing of eligible expenses at healthhub.com.
After The Claim Submission Deadline
• The minimum annual election is $100; the maximum
annual election is $2,500.
• FSA Rollover Feature
You are able to roll over up to $500 in unused Health FSA funds into the next plan year.
Determining Your Annual Election
• After September 28th, any funds in excess of $500
that remain in your Health FSA will be forfeited in accordance with IRS regulations.
Use the tools on healthhub.com to determine your
out-of-pocket health expenses and annual election.
To determine your Health FSA bi-weekly deductions, divide your total annual election amount by the number of pay periods in the plan year (26). If you are eligible after the start of the FSA plan year, divide your total election by the number of pay periods remaining in the plan year.
Health FSA Reminders
• Annual re-enrollment is required for Health FSA plans.
Receiving Reimbursement
•
You may receive automatic reimbursement on qualified Health FSA expenses by using the PayFlex CardTM, or you may submit claims. Visit healthhub.com for more reimbursement information.
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All expenses must be for incurred expenses, not
for future expenses. Expenses cannot have
been previously reimbursed and must not be reimbursable by insurance or any other source.
Dependent Care FSA
FSA questions?
Contact Payflex at 1-800-284-4885
or visit healthhub.com
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (FSA)
What Is A Dependent Care FSA?
Important FSA Dates
A Dependent Care FSA allows you to set aside money on a
pre-tax basis for day care expenses for your child, disabled
parent or disabled spouse.
•
Eligible expenses include payments to day care centers, preschool costs, after school care
and elder care. You may view a full listing of eligible expenses at healthhub.com.
•
The minimum annual election is $100; the maximum annual election is $5,000 per calendar
year ($5,000 is the maximum amount both you
and your spouse, combined, may contribute to a Dependent Care FSA).
• You may incur claims throughout the plan year, which
runs July 1, 2016 to June 30, 2017.
• You are afforded an additional 90 days from the end
of the plan year (until September 28th) to submit any claims that you have incurred.
Use It Or Lose It!
• After September 28th, any funds that remain in your Dependent Care FSA will be forfeited in accordance with IRS regulations.
Determining Your Annual Election
Use the tools on healthhub.com to determine your
dependent care expenses and annual election.
To determine your Dependent Care FSA bi-weekly
deductions, divide your total annual election amount by the
number of pay periods in the plan year (26). If you are eligible
after the start of the FSA plan year, divide your total election
by the number of pay periods remaining in the plan year.
• Rollover of dependent care FSA funds is not permitted.
Dependent Care FSA Reminders
•
The Dependent Care FSA is for day care expenses. If your dependents will incur eligible health expenses, this should be included in your Health FSA election.
• Annual re-enrollment is required for the
Dependent Care FSA plan.
•
Reimbursement For Dependent Care Expenses
The PayFlex CardTM cannot be used for Dependent Care
FSA expenses. You will need to submit claims for
reimbursement. Visit healthhub.com to learn about dependent care claim submission options.
You will only receive reimbursement for dependent care expenses that allow you and
your spouse to actively work, seek employment
or attend school on a full-time basis.
• Reimbursement for dependent care expenses cannot exceed your account balance.
• Dependent care expenses must be for services received, not for future services.
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Life Insurance questions?
Contact Liberty Mutual at 1-888-787-2129
or visit mylibertyconnection.com
Life/AD&D
LIFE INSURANCE
Basic Life And Accidental Death & Dismemberment Insurance
URBN provides you with Basic Life Insurance through Liberty Mutual in an amount equivalent to your base annual earnings to
a maximum of $100,000. An equal amount of AD&D Insurance is also provided. This coverage is entirely company paid and
requires no contribution on your part. The company code for your Basic and Voluntary Life Insurance benefits is: URBNINC.
Voluntary Life Insurance
If you need additional coverage beyond the Basic Life
Insurance benefit, you may elect Voluntary Life Insurance.
Voluntary Life – Initial Eligibility
• Newly eligible employees may elect up to $100,000 for themselves and up to $10,000 for their spouse in Voluntary Life coverage without
having to complete a Statement of Health form.
• Employee Voluntary Life Benefit
Coverage is available in $10,000 increments, up
to $500,000.
•
Voluntary Life – Open Enrollment
Spouse Voluntary Life Benefit
If you elect coverage for yourself, you may purchase
coverage for your spouse in $10,000 increments up to
50% of your coverage amount.
• Child Voluntary Life Benefit
Coverage may be purchased in amounts of $5,000
or $10,000.
The amount that you will pay for Employee and Spouse
Voluntary Life coverage is based on your age and your desired
coverage amount. The cost you will pay for Voluntary Child
Life coverage is based on a flat rate and can be viewed online.
•
Employees may increase their Voluntary Life coverage by one increment of $10,000 (up to $100,000) each annual Open Enrollment without completing a Statement of Health form.
•
Employees wishing to increase their Voluntary Life coverage by more than one increment of $10,000, or wishing to increase their coverage
to an amount greater than $100,000, will be required to complete the Statement of Health form.
• Any increase to your Spouse Voluntary Life
coverage requires that your spouse complete the
Statement of Health form.
Visit the Plan Information/Common Forms & Plan
Information section of portal.adp.com for a
Statement of Health form.
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Ancillary Benefits
Questions?
Contact Liberty Mutual at 1-888-787-2129
or visit mylibertyconnection.com
ANCILL ARY BENEFITS
If you are covered under an URBN group life insurance plan, you receive the following ancillary benefits through Liberty Mutual.
Employee Assistance Program
The EAP is designed to help ensure there is a balance between your work responsibilities and your personal life by offering a
number of helpful services and programs. EAP services and resources are available to you and your family members 24 hours a
day, 7 days a week and are strictly confidential. Some of the services available through the EAP are listed below.
Services
• 5 face-to-face sessions
Financial
1
• 24-7 telephonic assistance
- Personal/Marital/Family
- Alcohol/Drug abuse
- Stress/Anger
- Death and dying
• Online Services
1
In California, sessions are limited to three
(3) in a six-month period, not to exceed a
total of 5 sessions per year.
• Toll free information line
- Credit
- Debt
- Request educational material
• Financial advice sessions
- Scheduled phone counseling
session and financial worksheet
review
Legal
Family
• Assistance from attorneys
• Access to information:
• Assistance with:
• Telephonic assistance
- One free 30 minute telephonic
or face-to-face session
- 25% employee discount on
additional services
- Document preparation
- Divorce/separation
- Real estate
- Civil matters
- Child care
- Adoption
- Elder care
- Education
- One free 30 minute telephonic
session
• Web access:
- Available 24/7
To take advantage of the services available through the EAP, please call 1-877-695-2789 (1-877-MYLBRTY) or visit
bensingerdupont.com/MLA (Password: MLASSIST).
Travel Assistance Program
Travel Assistance provides 24/7/365 access to pre-travel, personal, and emergency help with situations that may arise during
travel. Services are available to you while on business or personal travel more than 100 miles from home and for less than 90
consecutive travel days. Dependents traveling with you are also covered. Some of the services provided are listed below.
• Worldwide Destination Intelligence
• Travel Assistance Services
• Medical Assistance Services
• Medical Evacuation and Repatriation Services
• Security and Political Evacuation Services
For more information about the Travel Assistance Program, see
the FrontierMEDEX Liberty Program document posted in the
Plan Information/Common Forms & Plan Information section of
portal.adp.com.
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Disability questions?
Contact Liberty Mutual at 1-888-440-6118
or visit mylibertyconnection.com
Disability
DISABILIT Y INSURANCE
Short-Term Disability Insurance1
A Short-Term Disability (STD) benefit through Liberty Mutual is provided at no cost to you should you become disabled for more than two weeks due to sickness, injury, or pregnancy and delivery. This coverage provides a weekly benefit that equals
60% of your base weekly salary to a maximum of $1,000.
• STD – Due to Sickness or Injury
After an unpaid elimination period of 2 weeks (14 consecutive days), benefits are payable for 11 weeks for a maximum disability duration of 13 weeks per disability.
• STD – Due to Pregnancy and Delivery
After an unpaid elimination period of 2 weeks (14 consecutive days), benefits for a vaginal delivery are payable for 4 weeks for a maximum disability duration of 6 weeks. After the elimination period, benefits for a cesarean section are
payable for 6 weeks for a maximum disability duration of 8 weeks.
iling a short-term disability claim is easy. If you become disabled, you may file your claim online at mylibertyconnection.
F
com or by calling the Liberty Mutual Claims Center at 1-888-440-6118. View the “Reporting Your Disability Claim”
document in the Plan Information/Common Forms & Plan Information section of portal.adp.com for details.
Long-Term Disability Insurance
If you remain disabled for 90 consecutive calendar days due to any one disabling illness or injury, you will be eligible to receive the company paid Long-Term Disability (LTD) benefit available to you that provides 60% of your base monthly salary to a maximum of $3,000.
Employees whose annual base salary is such that 60% of their base weekly salary exceeds $1,000, may purchase additional coverage through a Buy-up STD plan option.
If you are eligible for this benefit, it will be available to you on the enrollment website, along with further information regarding the benefit amount and cost.
1
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Voluntary Benefits
Critical Illness or Accident Insurance questions?
Contact VOYA at 1-888-287-4162
VOLUNTARY BENEFITS
New for 7.1.2016
Critical Illness Insurance
Accident Insurance
What Is Critical Illness Insurance?
What Is Accident Insurance?
Critical illness insurance pays a lump-sum benefit if you are
diagnosed with a covered disease or condition1. You can use
this money however you like, for example: to help pay for
expenses not covered by your medical plan, lost wages, child
care, travel, home health care costs or any of your regular
household expenses. Critical Illness Insurance is a limited
benefit policy.
Accident insurance pays you benefits for specific injuries
and events resulting from a covered accident1. You can use
this money however you like, for example: deductibles,
child care, housecleaning, groceries or utilities. Accident
Insurance is a limited benefit policy. Benefits for services
related to a covered accident include (but are not limited to):
•
•
•
•
If you enroll in critical illness insurance coverage, you
have access to the Wellness Benefit. The Wellness Benefit
provides an annual benefit if you complete a health
screening test, whether or not there were any out-of-pocket
costs. This benefit is designed to encourage you to maintain
a healthy lifestyle as the tests can help screen for a wide
range of potential illnesses and diseases.
Who Is Eligible For Coverage?
• Full-time employees
• Your spouse under the age of 70
• Your children to the age of 26
Who Is Eligible For Coverage?
• Employee • Spouse • Child • Full-time employees
• Your spouse under the age of 70
• Your children to the age of 26
How Much Does Accident Insurance Cost?
Covered
How Much Coverage Is Available?
Hospital care - surgery, hospital admission
Follow up care - medical equipment, physical therapy
Common injuries - burns, fractures
Emergency care benefits
$15,000 or $30,000
$5,000 or $10,000
$2,500 or $5,000
High Option
Low Option
Employee Only
$5.26
$3.66
Employee + Spouse
$8.76
$6.09
Employee + Children
$10.33
$7.18
Employee + Family
$13.84
$9.62
There are no medical questions to answer. Employee coverage is required in order to elect Spouse and/or Child coverage. For
more information, please refer to the Critical Illness and Accident Enrollment at a Glance (EAG) documents posted in the Plan
Information/Common Forms & Plan Information section of portal.adp.com or call 1-888-287-4162.
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See the product brochure, certificate of coverage and any applicable riders for a complete list of covered conditions, along with complete provisions, exclusions and limitations.
12
Whole Life Insurance questions?
Contact VOYA at 1-888-287-4162
Voluntary Benefits
VOLUNTARY BENEFITS
New for 7.1.2016
Premier Whole Life Insurance
What is Whole Life Insurance?
Whole Life Insurance is an individual life insurance policy that pays a benefit to your beneficiary if you pass away. Your premium
payments will stay the same for the life of the policy, as long as you meet the required premium payments. Plus, the policy builds
cash value, which you can borrow against. Any unpaid loan would be subtracted from the benefit that is paid to your beneficiary.
Who Is Eligible For Life Insurance?
Premier Whole Life
• Full-time employees
• Your spouse under the age of 70
• Your children to the age of 24
• For you—If you are under age 65, you may elect up
to $20.00 per week not to exceed $100,000 of
life insurance without answering health questions.
If you are age 66 or older, you may elect up to
$25,000 not to exceed $100,000 with some
health questions required for coverage.
How Much Coverage Is Available?
• For you-Eligible for the greater of what $20/week
would purchase or $100,000
• For your spouse-Eligible for the greater of what
$5/week would purchase or $5,000
• For your child(ren) and/or grandchild(ren)-Eligible
for $12,500, $15,000, $20,000 or $25,000
in coverage.
• For your spouse*—You may elect the greater of
$5 per week or $5,000 not to exceed $5,000 of
life insurance on your spouse through age 65 with
some health questions. Spouses age 66 through 70
will need to answer health questions and be fully
underwritten for any amount of coverage.
• For your children—You may elect $12,500,
$15,000, 20,000, or $25,000 of life insurance on
your children with some health questions.
To ENROLL or get more details regarding the specific
premiums with the various benefits, call 1-888-287-4162
to speak with a licensed insurance counselor.
*Amounts applied for above the guaranteed issue limits
will require additional underwriting.
Visit the Plan Information/Common Forms & Plan
Information Section of portal.adp.com for more
information.
Insurance products issued by ReliaStar Life Insurance Company, a member of the Voya® family of companies. Home and Administrative Office: 20 Washington Avenue South,
Minneapolis, MN 55401. Policy provisions and product availability may vary by state.
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Be Well
WELLNESS BENEFITS
Health Advocate
Healthy Lifestyle Solutions
Health Advocate provides a range of services designed to
help you and your family navigate the healthcare system.
Their team of personal advocates and nurses are available to
you and your immediate family members. Health Advocate
is a great service if you need assistance finding a new
provider; they can run the search for you, give you a list
of options, and even schedule your appointment for you
once you choose the doctor that best fits your needs. If
you have any problems related to claims or reimbursements
with any of the benefit providers, Health Advocate can
resolve the issues on your behalf. If you or a family member
is diagnosed with an illness or condition, you may call
Health Advocate to speak with a nurse and obtain more
information. The cost for Health Advocate’s services for you
and your family is fully paid by URBN. There is no waiting
period; you may use Health Advocate’s services as soon as
you become a benefit-eligible employee.
This program provides reimbursements and discounts for a
variety of programs and services when you take steps toward
improving your health. Approved reimbursements are
available for the following types of programs:
• Weight-loss programs/gym membership
• Smoking cessation
• Alternative health services
View the Healthy Lifestyle Solutions brochure in the Plan
Information/Common Forms & Plan Information section of
portal.adp.com for more details.
Baby Blueprints®
Staying healthy during your pregnancy may reduce the risk
of complications, premature babies, and low birth weight.
As soon as you learn that you are expecting, you may enroll
in the Baby Blueprints® program at no cost. The program
includes educational materials and access to obstetric
nurses who provide case management for high-risk pre-natal
conditions. For more information call 1-800-ASK-BLUE or
visit ibxpress.com.
Call 1-866-695-8622 or visit healthadvocate.com to access
Health Advocate’s confidential services.
Nutrition Counseling Plan
Complimentary nutrition and wellness counseling is
available to you and your enrolled dependents. The
nutrition counseling plan through Independence Blue Cross
covers up to 6 visits per year with a participating dietician,
physician, or nutrition counselor at no cost to you. To get
started, visit ibxpress.com to find a network provider and
schedule your nutrition counseling appointment.
GlobalFit
Discounted gym memberships and reduced initiation fees
to over 10,000 fitness clubs nationwide are available
through the GlobalFit program. This program is available to
all employees and their immediate family members. To get
started visit www.globalfit.com/urbn or call
1-800-294-1500.
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Employee Contributions
EMPLOYEE BI-WEEKLY CONTRIBUTIONS
Here are the pre-tax costs based on 26 pay periods per year for each plan.
Medical
Coverage Levels
Base Plan
Core Plan
Employee
$45.06
$55.91
Employee + 1
$101.86
$124.05
Family
$137.30
$168.79
Dental
Coverage Levels
Dental Plan
Dental Plus Plan
Employee
$6.46
$13.83
Employee + 1
$12.55
$26.74
Family
$20.06
$43.01
Vision
Coverage Levels
Vision Plan
Vision Plus Plan
Employee
$2.16
$5.00
Employee + 1
$4.32
$10.00
Family
$6.97
$16.10
Flexible Spending Accounts
To determine your FSA bi-weekly deductions, divide your total annual election amount by the number of pay periods in the plan year
(26). If you are eligible after the start of the FSA plan year, divide your total election by the number of pay periods remaining in the
plan year.
Voluntary Life Insurance
To view your Voluntary Life rates, please visit portal.adp.com.
Voluntary Benefits
To view your Voluntary Benefits rates, please visit portal.adp.com.
IMPORTANT PL AN NOTE:
When you enroll for coverage under the Plan, you agree to make a specified dollar contribution on a per pay period basis independent of your coverage dates. In other
words, contributions are not associated with any particular period of coverage and are not pro-rated at either the initial or terminal pay period.
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Benefit ID Cards
HOW TO OBTAIN OR REPL ACE YOUR BENEFIT ID CARDS
Medical (Independence Blue Cross)
To obtain a new medical card, you may log on to ibxpress.com or call 1-800-ASK-BLUE.
Prescription (Express Scripts, Inc.)
To obtain a new prescription card, you may log on to express-scripts.com or call 1-800-818-0093.
Dental (MetLife)
MetLife does not issue ID cards, but you may download a printable card pre-populated with your information at
metlife.com/mybenefits. The group number is 100762.
Vision (VSP)
VSP does not issue ID cards. Your VSP “Choice” provider will identify your insurance using your Social Security Number. If you choose a provider outside of the VSP “Choice” network, you will pay for services and products in full and submit your claim at vsp.com.
Health FSA (Payflex)
To obtain a new Health FSA PayFlex Card™, you may log on to healthhub.com or call 1-800-284-4885.
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Questions?
Email [email protected]
Enrollment Checklist
SO YOU THINK YOU’VE ENROLLED?
If you miss your enrollment deadline or do not verify your dependents timely, your enrollment will not be complete. Each
enrollment step is crucial. As much as URBN would love to make an exception for missed enrollments, we must comply with
IRS rules and exceptions or deadline extensions are never possible.
To Ease Your Mind, Use This Handy Checklist To Ensure That You’ve Completed The Entire Enrollment Process.
 Did you go to portal.adp.com and complete the enrollment process by reviewing your options and choosing to enroll
or waive enrollment for each elective benefit option?
 Did you review the new voluntary benefits?
 Did you designate a beneficiary for your basic life insurance plan? Even if you are not electing benefits, it’s imperative that you identify a beneficiary for your company-paid life insurance policy.
 Did you click “Finish” to submit your benefit elections online at portal.adp.com?
 Did you print or save a copy of your confirmation statement?
If you have enrolled dependents, you will then receive a letter and list of required documentation in the mail. Please follow
the instructions outlined in the documents.
 If you are enrolling due to a Qualifying Life Event, did you declare your event online at portal.adp.com?
If You’ve Answered Yes To All Questions On This Checklist, You’ve Successfully Enrolled For Your Benefits!
Note the effective date of your benefits on your confirmation statement and get ready to access all of your health and
wellness benefits on that date.
For more details about your coverage and all of the great perks that come along with your benefits, visit the Plan
Information/Common Forms & Plan Information section of portal.adp.com.
Still Not Sure?
Questions? Email [email protected].
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Qualifying Life Event
Report a Qualifying Life Event online at
portal.adp.com
QUALIF YING LIFE EVENT (QLE)
In accordance with IRS rules, the benefit elections you make during Open Enrollment are binding through the duration of
the plan year (July 1, 2016 - June 30, 2017). The only exception to this rule occurs if you experience a Qualifying Life Event.
A Qualifying Life Event, sometimes referred to as a “QLE”, is an event specified under IRS guidelines that permits you to
change certain benefit and dependent elections at a time other than the annual open enrollment period. Permissible elections
depend on the nature of the event. Your QLE elections must be consistent with and directly caused by the event. You have
30 days from the date of the event to declare your qualifying life event and make your benefit elections (60 days for QLEs
associated with CHIP and Medicaid; 90 days for QLEs associated with birth or adoption). See To Declare Your Qualifying Life
Event instructions below. New elections will be retroactive to the date of the QLE. Once you have declared your QLE, you will
receive audit information requesting the sufficient proof items via email and hard copy letter. The information you provide will
be used to audit dependents added to coverage and the event used to add them.
Common Qualifying Life Events Include
•
•
•
•
•
•
•
Marriage
Birth, adoption or placement for adoption of an eligible child (90-day election period)
Divorce, legal separation or annulment
Gain or loss of other coverage
Death of spouse or dependent
Gain or loss of eligibility for Medicaid, a state Children’s Health Insurance Program (CHIP) or a premium assistance subsidy
under either of these programs (60-day election period)
Receipt of a qualified medical support order
To Declare Your Qualifying Life Event
• Visit portal.adp.com and log in with your username and password, then click on “Declare Life Event”
• Select an event from the drop-down list, enter a valid date for the event, and then select Submit
If you have any questions about reporting your QLE, please contact the Benefits Department at [email protected]
for assistance.
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401(k) questions?
Contact Fidelity at 1-800-835-5097
or visit 401k.com
401(k) Retirement Plan
401(K) RETIREMENT PL AN
One way to save for your future retirement is to participate in the Urban Outfitters, Inc. 401(k) Savings Plan managed by Fidelity
Investments. Below is some information about the Plan:
You Can Take Your Vested Balance With
You If You Leave The Company.
Here Are Your Options:
Enrolling In The 401(k) Plan:
• You may enroll in the Plan once you have completed 3 months of service.
• Roll your account over to a 401(k)
with your new employer.
Your Pre-Tax Contribution Percentage Is Yours
To Select:
• Roll your account over to an IRA (Individual Retirement Account).
• You can contribute up to 25% of your salary. If you are age 50 or above, you
can make an additional catch-up contribution.
• Take a cash distribution. In this situation,
a mandatory 20% tax will be withheld, and
an additional 10% tax penalty may apply.
• All savings and earnings grow tax-free until
withdrawn, allowing you to take full advantage of compound growth.
Consolidate Your Retirement Savings:
• If you are not eligible for the Plan yet,
no problem. Rollovers into the Plan are
accepted immediately upon hire.
Urban Outfitters Will Match A Portion Of Your Contributions To The Plan:
• Call Fidelity at 1-800-835-5097 for assistance.
• Urban Outfitters matches 25% of your contributions up to 6% after you reach one year of service.
•
Your contributions to the Plan are
immediately vested, but the match is subject
to a vesting schedule. Each year that you
remain with the Company, you gain an additional
20% ownership of match contributions, becoming
100% vested after 5 years.
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When Health Benefits End
WHAT HAPPENS TO YOUR BENEFIT COVERAGE
Medical, Prescription, Dental And Vision Benefits:
• Coverage ends the date you terminate employment.
•Continuation of health insurance coverage is available under the Consolidated Omnibus Budget Reconciliation Act of 1986
(COBRA). COBRA will allow you to continue your current medical, prescription, dental, vision and health FSA benefits
for up to 18 months.
• Approximately 3-4 weeks after your termination or status change has been processed, you will receive a package of
information describing the COBRA benefits. This package will be sent to the home address we have on file for you, so
please be sure we have your most up-to-date contact information before you leave!
•The COBRA packet will be sent from a company by the name of ADP COBRA Services, who is the administrator of our
COBRA program. Should you elect coverage under COBRA, you will need to return the completed COBRA enrollment
form, along with payment, to ADP COBRA Services. ADP COBRA Services will then send you monthly coupon
statements for you to maintain payments each month thereafter.
•If you fail to make a payment, your COBRA coverage will be terminated and you will not be allowed to re-enroll.
•If you choose to elect COBRA, the COBRA start date will revert back to the first day your coverage ended as an active
employee. If you should incur any claims for medical, prescription, dental or vision during the time you are waiting for the
COBRA coverage to initiate, email [email protected] for assistance.
•For more information regarding COBRA, please contact our administrator at 1-800-526-2720.
IMPORTANT PL AN NOTE:
When you enroll for coverage under the Plan, you agree to make a specified dollar contribution on a per pay period basis independent of your coverage dates. In other
words, contributions are not associated with any particular period of coverage and are not pro-rated at either the initial or terminal pay period.
*Marketplace Coverage - Another way to obtain health coverage is through the Marketplace.
The Marketplace offers individuals a way to find and buy health insurance. Help paying for coverage (through subsidies) within the
Marketplace may be available, making health insurance more affordable to qualified individuals.
If you choose this option, you cannot continue your current URBN benefits, but you can enroll in new plans. For more information
about your plan options and/or to enroll in Marketplace coverage, visit www.getinsured.com/mercer or call 1-877-917-7957 to have
a personal enroller assist you.
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Notes
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Provider Contacts
MEDICAL (IBC)
1-800-ASK-BLUE
ibx.com
TELEMEDICINE (MDLIVE)
1-877-764-6605
mdlive.com/ibx
RX (EXPRESS SCRIPTS)
1-800-818-0093
express-scripts.com
DENTAL (METLIFE)
1-800-GET-MET8
metlife.com/mybenefits
VISION (VSP)
1-800-877-7195
vsp.com
FSA (PAYFLEX)
1-800-284-4885
healthhub.com
LIFE (LIBERTY MUTUAL)
1-888-787-2129
mylibertyconnection.com
DISABILITY (LIBERTY MUTUAL)
1-888-440-6118
mylibertyconnection.com
VOLUNTARY BENEFITS (VOYA)
1-888-287-4162
HEALTH ADVOCATE
1-866-695-8622
healthadvocate.com
EAP (LIBERTY MUTUAL)
1-877-MYLBRTY
bensingerdupont.com/MLA
401(K) (FIDELITY)
1-800-835-5097
401k.com
to access your benefits online visit: portal.adp.com
for questions, contact us at: benefitsdepartment @ urbn.com
follow us on twitter @ urbn_benefits
About This Benefits Summary: The Urban Outfitters, Inc. plan year runs from July 1, 2016 through June 30, 2017. This benefits summary describes the highlights of our benefits in nontechnical
language. Your specific rights to benefits under the plan are governed solely, and in every respect, by the official plan documents and not the information in this benefits summary. If there is any discrepancy between
the description of benefits in this summary and the official plan documents, the language of the official plan documents shall prevail. Please refer to the plan-specific documents for detailed plan information. Any of
these benefits may be modified at the sole discretion of Urban Outfitters, Inc. Plan documents, amendments, and summaries of material modifications may be found online at portal.adp.com. This benefits summary
may not be reproduced or redistributed in any form or by any means without express, prior permission in writing from Urban Outfitters, Inc.
URB-OPM-2016-BR-7