2016 benefits look book€¦ · home hello, 2016 benefits! benefits to fit your style 2016 price...

At Lucky Brand, we know that our success depends on our people. One of the ways we

reward our associates for their contributions is by offering comprehensive, high-quality

benefits at a reasonable cost. These benefits are designed to protect your health, your family,

and your wealth, and they’re a valuable part of the compensation package Lucky Brand offers.

This guide is meant to help you find the perfect benefits fit. Use it like a website to find all the

information you need to make thoughtful decisions about your benefits, and to help you live a

happy and healthy Lucky life.

Look good. Feel good. Do good.

Lead a Lucky life.

2016 Benefits Look Book

HomeHello, 2016 Benefits!

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Welcome to Your 2016 Benefits

Hello, 2016 Benefits!THIS IS IMPORTANT: Check out the new benefits package for 2016! It’s a benefits refresh.

We’re talking about your total well-being. Not just your body and mind, but your financial health too — in and out of the workplace. Learn about Open Enrollment and your new benefits package.

Enroll in Your Plans by October 31. You must take action! Open Enrollment is October 19 through October 31, 2015. This is your chance to choose your Lucky Brand benefits coverage for 2016. So click through this guide. Ask questions. Figure out which plans fit your needs.

• Compare your medical, dental, and vision options.

• Learn how to save money with Flexible Spending Accounts (FSAs).

• See your “safety net” benefits and determine if you want to buy more.

• Confirm if your family is eligible for benefits.

• Enroll by the October 31 deadline.

If You Don’t Take ActionYou will not have medical, dental, or vision coverage for 2016. You will only have company-provided benefits, such as disability, life, and AD&D insurance coverage.

Remember: Open Enrollment only happens once a year. After this, you can only make changes during the year if you have a qualifying life change event.

Hello, 2016 Benefits!

Enroll in Your Plans by October 31

• If You Don’t Make Changes

New Arrivals for 2016

• New Medical Plan Options

• Changes to Traditional PPO

• New Dental and Vision Plans

• Life, Accident, and Disability

Through Cigna

• Commuter Benefits for All

Need Help Deciding?Don’t worry, our Plan Cost Estimator Tool makes it easy for you to find the plan that’s best for you.

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New Arrivals for 2016For 2016, we are making a few show-stopping enhancements to your benefits to bring you more choice, flexibility, and control over your coverage and your spending. Get excited and check out our new stuff below.

New Medical Plan OptionsLucky Brand will offer two new kinds of medical plans in 2016, the Lucky Choice High Deductible Health Plan (HDHP) and Lucky Choice High Deductible Health Plan (HDHP) Saver. We’re thrilled to offer you this coverage in addition to your Lucky Choice PPO plan option and a Kaiser Permanente HMO option (available to the California corporate office and Hawaii residents only). Plus, these HDHPs come with lower paycheck contributions AND a unique tax-advantaged savings account, called the Health Savings Account (HSA).

Get the skinny on these plans, including their money-saving capabilities, here. Or, better yet, get ALL the facts in the Lucky Choice High-Deductible Health Plan (HDHP) User Toolkit.

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Through Cigna


Grab Your PopcornWatch these videos to learn more about your new plan options or make enrollment decisions.

https://luckybrand.a.guidespark.com/videos/35211%20








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Changes to the Lucky Choice PPO PlanFor those who love this tried-and-true plan, the Lucky Choice PPO plan’s deductibles and out-of-pocket maximums will increase slightly for 2016. View the amounts in the Medical Benefits at a Glance section.

New Dental and Vision PlansIn addition to our current dental and vision offerings, you will now have the choice to enroll in additional options for these plans.

• Lower-cost dental coverage: If teeth cleaning, X-rays, and the occasional cavity are what you need dental coverage for most, you’re going to like our new lower-cost dental plan. You now have the option to select the Saver Dental PPO. Learn more about this new coverage here.

• Enhanced vision coverage: If you need greater vision coverage than is currently available, such as a higher frame allowance for those designer frames, you now have the option to select the Premium Vision plan. Get a good look at your vision plan options here.

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Through Cigna







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Life, Accident, and Disability Insurance Now Provided through CignaWe’re changing things up a little bit with your life, accident, and disability insurance benefits. They’ll now be provided through Cigna. Here’s what you need to know about the change.

Life Insurance • Active Enrollment — You will need to re-elect your life insurance coverage for 2016. Good news! You will not have to provide Evidence of Insurability (EOI) for electing the same coverage level as you have in the 2015 plan year. However, we do encourage you to review your elections, as you have new benefit levels available for spouse and children.

• Beneficiary designations — You will need to specify your beneficiary elections in the Workday system since they won’t be transferring from Aetna.

• Evidence of Insurability (EOI) — This is a new opportunity for you to enroll yourself and your loved ones in “safety net” coverage. Proof of good health (also known as EOI) will only be required on benefit amounts above the Guaranteed Issue amount. Learn more here.

Accident Insurance

• Active Enrollment — You will need to re-elect your AD&D coverage for 2016. Again, good news! You will not have to provide EOI for electing the same coverage level as you have in 2015, but do take a minute to review your coverage and ensure you’ve got the right amount to secure your financial future.

Disability Insurance

• Continuation of benefit — Since short-term disability and long-term disability are provided to you for FREE by Lucky Brand, your disability coverage will continue into 2016.









Through Cigna


http://www.myworkday.com/luckybrand.






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Commuter Benefits for All, Now Provided Through Discovery BenefitsGood news! Commuter Benefits are now available to employees eligible for benefits through Lucky Brand! This benefit allows you to use pre-tax dollars to pay for eligible commuting and parking expenses — because who wants to pay more for your parking spot or bus fare than you’re already paying? Learn more about your Commuter Benefits to get started!

If you currently have the Commuter Benefit: Beginning January 1, 2016, this plan will be administered by Discovery Benefits. If you have any unused funds in your WageWorks account at the end of the year, your account and benefit balance will be transferred to Discovery Benefits and you’ll be given a new debit card. For more information about this transition, contact Discovery Benefits.









Through Cigna







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Benefits to Fit Your StyleWe know you like options. Lucky Brand offers a number of benefits to choose from so that when it comes to making your choice, you can pick what’s right for you. Do you know what else? We have more options than ever before for 2016:

Medical Plans

• Lucky Choice PPO

• Lucky Choice HDHP

• Lucky Choice HDHP Saver

• Kaiser Permanente HMO (available to CA corporate office or Hawaii residents only)

Dental Plans

• Cigna Saver Dental PPO

• Cigna Traditional Dental PPO

Vision Plans

• VSP Traditional Vision Plan

• VSP Premium Vision Plan

Understand the LingoWhen choosing a medical, dental, or vision plan, it’s important to understand the lingo.

Show Me the SavingsHow much do these new plans cost? Check out your 2016 Price Tags.

Benefits to Fit Your Style

Medical Plans


• Lucky Choice High Deductible

Health Plans (HDHPs)

• Kaiser Permanente HMO

• Find the Right Fit

• Medical Benefits at a Glance

Dental Plans


• What You’ll Pay for Care

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Medical Plans Let’s be honest — choosing a medical plan isn’t fun. That’s why Lucky Brand offers three types of plans for our diverse team:

• A Preferred Provider Organization (PPO)

• A Health Maintentance Organization (HMO)

• Two high deductible PPO plans with Health Savings Accounts (HSAs).

But those are just the fancy names. Let’s take a look at what the medical plans really do.

First, all plans give you comprehensive medical coverage, including preventive care and prescription drugs, and they all have out-of-pocket maximums — a feature that limits what you pay in any year if you have large medical expenses.

So, which plan is right for you? The choice depends on what fits you and your family best.

No-Cost Annual Check-UpsAll Lucky Brand medical plans cover in-network preventive care, like physicals and recommended screenings, for FREE.


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Get the Perfect FitThe Plan Cost Estimator Tool can help you determine which plan works best with your personal needs. Go ahead — try it out!









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Lucky Choice PPOThis is your regular, ol’ PPO plan. You can receive care from any licensed provider. However, you’ll pay less when you receive care from physicians, hospitals, and other health care facilities participating in United Healthcare (UHC)’s network. Don’t worry, we have directions for finding a UHC doctor near you.

Once you’ve met the deductible, you’ll pay a percentage of the cost (coinsurance) for each service until you reach the annual out-of-pocket maximum. Some services, such as in-network office visits or generic prescription drugs, require only a copay.

You can see specific details about this plan in the Medical Benefits at a Glance section.

Sounding like gibberish to you? Get refreshed on your medical plan terminology.

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UHC’s Virtual Visits — Speak with a Doctor Online or by Phone. Anytime.If you’re enrolled in a UHC medical plan, you will have 24/7 access to physicians through Virtual Visits, UHC’s telemedicine program.

You pay a copay when you need to use the service, and you can speak with a doctor at any time, online or by phone.

To get started, visit www.myuhc.com.


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Lucky Choice High Deductible Health Plans (HDHPs) You can choose either the Lucky Choice HDHP or the Lucky Choice HDHP Saver.

You can see any licensed provider, but you’ll receive the highest level of coverage when you choose one from the UHC’s network. Find a UHC doctor near you — see directions to the right. Additionally, with these plans, preventive medications are not subject to the deductible, which means that you can pay for these medications with coinsurance right away.

You can see specific details about this plan in the Medical Benefits at a Glance section.

The HSA: A Unique Plan FeatureUnlike the Lucky Choice PPO, these plans have relatively high annual deductibles. But don’t let that scare you away. As a tradeoff for the higher deductibles, you get access to a Health Savings Account (HSA). The HSA is a tax-advantaged savings account where you can save money to pay for eligible medical expenses. And as a bonus, in 2016, Lucky Brand also puts money into your HSA as long as you make a mimumum annual contribution.

And it gets better! Your HSA money rolls over from year to year, and any balance, including Lucky Brand’s contributions, go with you if you leave Lucky Brand.

Discovery Benefits administers our HSA accounts. Visit their website at www.discoverybenefits.com for HSA tools and resources. See the next page for additional details about these unique plans.

Looking for a UHC doctor?Locate a nearby provider who participates in your network:

Visit www.myuhc.com.

Click “Find a Physician, Laboratory or Facility” on the right side of the page.

Select the network name based on your location:

• Inside California: Select Plus network

• Outside California: Choice Plus network


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Put Money in the BankThe IRS limits how much you and Lucky Brand can put into your HSA each year:

• If you have “Individual” coverage: Up to $3,350

• If you have “Family” coverage: Up to $6,750

Here are the amounts that you and Lucky Brand can contribute to your HSA in 2016:

Tier LevelWhen you contribute …

Then, Lucky Brand will contribute …

So, you can contribute this additional amount ...

Lucky Choice HDHP

Individual $250 $500 $2,600

Family $500 $1,000 $5,250

Lucky Choice HDHP Saver

Individual $250 $250 $2,850

Family $500 $500 $5,750

You can use this HSA money to pay your deductible and other medical expenses, or save it for future medical expenses — even in retirement.

Want to learn more? See the Lucky Choice High-Deductible Health Plan (HDHP) User Toolkit for in-depth information about how the HSA works, including domestic partner eligibility, and how to save on your medical expenses with these unique plans.

Age 55 or Older?If you’re age 55 or older, you can make an additional $1,000 catch-up contribution each year.

Press PlayThis HSA video can help you make the most of these Lucky Choice HDHPs. Take a look!


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UHC Resources at Your Fingertips

Use myHealth Cost Estimator Did you know that you could pay a different amount for the same medical procedure depending on where you go or who you see? Use the myHealthcare Cost Estimator online tool at www.myuhc.com to access cost information for doctors, services, and care centers.

The more you use the myHealthcare Cost Estimator, the more you’ll see that not all doctors are the same. Depending on what you’re looking for, you could see a wide range of estimates for the same procedure or treatment. You can search by condition or treatment with terms such as:

• Back pain

• X-rays

• MRIs

• Low thyroid

• Procedures

• Physical therapy.

You’ll also be able to learn about your care options, compare estimated costs, and see quality and cost-efficiency ratings. Most importantly, you’ll be able to make a more informed decision about what option is best for you.

Sometimes All You Need Is a Tour GuideIf you’re enrolled in a UHC medical plan, the Advocate4Me program gives you a simpler, more personal and informed experience when you need care. They offer resources to help you improve your health and make care more affordable. This service is provided to you at no additional fee. Advocates can help you:

• Understand your care options and coverage

• Make decisions about treatment options for you and your family members

• Find the best doctor or facility for your treatment, procedure or emergency

• Resolve your billing and claims issues

• Make sense of your health risks and lab results, and create an action plan for the future.

To get started, send an email to [email protected].


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Kaiser Permanente HMOThe Kaiser Permanente HMO options are only available for associates in the California corporate office and Hawaii only. The benefits of using an HMO are lower costs when you need medical care and the claims-free process. In exchange for those features, the HMO requires you to follow certain rules:

• You must receive all your care through providers who participate in the Kaiser Permanente network.

• Other than for emergencies, medical care you receive from providers outside the HMO’s network is not covered.

• You pay copays for most medical services.

We have all the details about these two plans in one place: the Medical Benefits at a Glance section.

Looking for a Kaiser Permanente Doctor?Locate a nearby provider or facility:

Visit www.kp.org

Click “Find doctors & locations” and follow the online prompts.

There’s an App for ThatDownload the KP Mobile App for Android or Apple smartphone. You can:

• Find a local doctor, network, or facility and make an appointment

• View, refill, and check the status of a prescription

• Check your latest test results

• Email your doctor.

Pretty cool, huh?


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www.kp.org

https://healthy.kaiserpermanente.org/health/care/consumer/ancillary/%21ut/p/a1/hZDBboMwEES_hiu7raMIuAFVEyApVG0D9SVyiEMsGRs5Vih_X6Cqcmozt9XO21kNUKiAKnYVDbNCKyanmS73z-lbHkUPIeYL38NkG6_j5CXDUVBCCrSR-jCbP8_WdoGDDtZaWa6s4erIDTcOArXiCFVZFEGwzeMNFtmquIfUdug4VEKdtGlvP_0fo1g7Mhdh-X5ef9l7CPuJYaoWUjIzQBkB3T19pH44oaE6EK8BavhpItyzvown-753G60byd1at2MRdO4KSfI6d7UqloiJl71nOz8jiI-_hj8UInStNxB53fDSEwRF-A1cReHP/dl5/d5/L2dBISEvZ0FBIS9nQSEh/






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Find the Right Fit Though all the Lucky Brand medical plans generally cover the same types of medical care and prescription drugs, they vary by how much you pay per-paycheck and when you visit a provider.

• Like the idea of free funding from Lucky Brand for your medical expenses? Take a look at the Lucky Choice HDHPs.

• Prefer having predictable health care expenses? Consider the Kaiser Permanente HMO, which has fixed costs for service, if it’s available to you.

• Want a low-deductible option with the flexibility to see any provider? The Lucky Choice PPO plan may be right for you.

Use this chart to help you find a medical plan that matches your priorities.

Choice of Providers Impact on Your Paycheck (compare prices here)

Annual Deductible

Lucky Choice PPO Freedom to choose any licensed provider. You pay less when you choose in-network providers

Highest per-paycheck price Lowest deductible of the PPO plans available to you

Lucky Choice HDHP

Freedom to choose any licensed provider. You pay less when you choose in-network providers

Moderate per-paycheck price (lower than PPO and HMO plans)

Moderate deductible, but offset by HSA dollars funded by Lucky Brand and you!


Freedom to choose any licensed provider. You pay less when you choose in-network providers

Lowest per-paycheck price Highest deductible of plans offered, but offset by HSA dollars funded by Lucky Brand and you!

Kaiser Permanente HMO (available to CA corporate office and HI residents only)

Limited choice. You must visit Kaiser Permanente providers and facilities only (except in emergencies).

Moderate per-paycheck price (less than PPO and more than the Lucky Choice HDHP plans)

No deductible


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Medical Benefits at a GlanceUHC Lucky Choice PPO UHC Lucky Choice HDHP UHC Lucky Choice

HDHP SaverCalifornia Kaiser Permanente HMO (available to CA corporate office only)

Hawaii Kaiser Permanente HMO (available to HI residents only)

In-Network Out-of-Network



In-Network In-Network

Annual Deductible

• Individual

• Family

$500

$1,500

$1,000

$3,000

$1,500

$3,000

$3,000

$6,000

$2,500

$5,000

$4,500

$9,000

No deductible No deductible

HSA Contribution from Lucky Brand

• Individual

• Family

Not available Required associate starter contribution: $250 for individual,

$500 for family

$500

$1,500

Required associate starter contribution: $250 for individual,

$500 for family

$250

$500

Not available Not available

Annual Out-of-Pocket Maximum

• Individual

• Family

$2,000

$4,500

$4,000

$9,000

$3,000

$6,000

$6,000

$12,000

$4,500

$6,850

$9,000

$13,700

$1,500

$3,000

$2,500

$7,500

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UHC Lucky Choice PPO UHC Lucky Choice HDHP UHC Lucky Choice HDHP Saver

California Kaiser Permanente HMO (available to CA corporate office only)






You’ll pay … You’ll pay … You’ll pay … You’ll pay … You’ll pay …

Office Visit

• Primary Care

• Specialist

$25 copay

$35 copay

30% after deductible





$20 copay

$20 copay

$15 copay

$15 copay

X-ray and Lab 10% after deductible






0% 10%

Preventive and Well-Woman Care

0% (no deductible)

Not covered

0% (no deductible)

Not covered

0% (no deductible)

Not covered

0% 0%

Maternity Care 10% after deductible






$20 copay per visit (with referral by physician)

0%

Well-Child Care 0% (no deductible)

Not covered

0% (no deductible)

Not covered

0% (no deductible)

Not covered

0% 0%

Continued


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Hospitalization

(Pre-certification required)







0% $75 copay per day

Outpatient Surgery







$20 copay per procedure

$15 copay per procedure

Emergency Room

10% after $100 copay (no deductible; waived if admitted); 30% after

deductible for non-emergency

20% after deductible 30% after deductible $100 copay (waived if admitted)

$75 copay (waived if admitted)

Continued


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Prescription Drugs

Pharmacy (30-day supply)

• Generic

• Preferred Brand Name

• Non-preferred Brand Name

$10 copay

$30 copay

50% ($30 min.; $60 max.)

Preventive drugs: 20% (deductible doesn’t apply)

All other drugs: 20% after deductible



$10 copay

$20 copay

$20 copay

$15 copay

$15 copay

$15 copay

Mail Order (100-day supply)

• Generic

• Preferred Brand Name

• Non-preferred Brand Name

$20 copay

$60 copay

50% ($60 min.; $120 max.)

Not covered



Not covered



Not covered

$20 copay

$40 copay

$40 copay

$30 copay

$30 copay

$30 copay

Prescription Drugs at a GlanceBenefits to Fit Your Style

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Dental PlansLucky Brand offers two dental options that help you pay for preventive, basic, and major care:

• Cigna Saver Dental PPO Plan

• Cigna Traditional Dental PPO Plan

Find the Right Fit Before choosing your plan, think about what kind of dental care you’ll need. Good dental health is key to your overall health.

The Cigna Saver Dental Plan may be right for you if you don’t use much dental care and if the following statements describe you and your family:

4 Your dentist gives you an A+ at your regular check-ups.

4 You don’t usually need services like fillings or root canals (basic dental care).

4 You cover yourself or other family members — and nobody needs braces in 2016.

The Cigna Traditional Dental Plan may be right for you if you need more dental care. Sound like you and your family? This might be the right plan for you if the following statements describe you and your family:

4 You want all the coverage you can get.

4 You might be paying for basic dental care (fillings, root canals, etc.) next year.

4 You or someone in your family needs braces or other orthodontia care.

Getting lost? Review the health care insurance lingo to get brushed up on your understanding.

Looking for a Dentist?Using Cigna participating dentists will save you money. To find one, visit www.mycigna.com.

Free Check-ups Both dental plans cover in-network preventive care, like routine exams and cleanings, for FREE.

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Compare Your Options Check out the chart below to compare your Lucky Brand dental plans.

What’s the Same? What’s Different?

• Administered by Cigna

• Freedom to choose any dentist — you receive higher benefits if you use a Cigna participating dentist

• Comprehensive preventive, basic, and major dental care

• Fully-covered in-network preventive services

• Individual annual deductible amount for non-preventive care

• 50% coverage for major services

Cigna Saver Dental Plan Cigna Traditional Dental Plan

• Lowest per-paycheck price

• Highest family deductible

• Lowest maximum benefit

• No orthodontia coverage

• Highest per-paycheck price

• Lowest family deductible

• Highest maximum benefit

• More coverage for basic services

• Orthodontia coverage for children and adults

Connect to CignaDownload the myCigna mobile app to see all your Cigna coverage — from dental plans to disability, life, and accident insurance — in one place. You can find a dentist, view your coverage info, review claims, and more!


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Link%20to%20http://www.cigna.com/aboutcigna/cigna-mobile/%255D

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What You’ll Pay for Dental CareCigna Saver Dental Plan Cigna Traditional Dental Plan

Maximum Benefit Amount per Calendar Year $1,000 per person $3,000 per person

You’ll pay …

Deductible

• Individual

• Family

$50

$150

$50

$50

Diagnostic and Preventive Services

Oral exam, cleanings (once every 6 months)

$0 in-network

80% out-of-network

Basic Services

Fillings, simple extractions, root canals

30% of the dentist’s approved fees, after

deductible

20% of the dentist’s approved fees, after

deductible

Major Services

Repair and maintenance of crowns, bridges, dentures

50% of the dentist’s approved fees, after deductible

Orthodontic Services Not covered Available for both children and adults;

50% of the provider’s approved fees, after deductible

$2,000 lifetime maximum benefit per person


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Vision PlansLucky Brand offers two vision plans through Vision Service Plan (VSP) that help you pay for eye exams, lenses, and frames:

• VSP Traditional Plan

• VSP Premium Plan

You can visit any optometrist or store, but you’ll save more — and avoid claim forms — by using providers who belong to VSP’s Signature network, including retail chain affiliate providers like Costco Optical and Visionworks®.

Looking for an Eye Doctor or Shop?VSP providers will have the glasses you’re looking for — whether your style is brainy, sultry, rock ‘n’ roll, or something that blurs the lines in between.

Find a list of VSP Signature in-network providers and local participating affiliate providers at www.vsp.com to get your look.

View VSP on the GoVSP’s mobile app gives you the vision plan information you need no matter where you are. You can find an in-network provider, view your coverage info, and even shop for frames! Get the app here.


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www.vsp.com

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Find the Right Fit Before choosing your plan, think about what kind of vision care you’ll need.

• With the VSP Premium Plan, you pay more up front — out of each paycheck — and less when you get care. If you like more lens options and want to update your signature look every year, consider this plan.

• With the VSP Traditional Plan, your per-paycheck price is lower, but you pay more when you get care. If you don’t need much vision care in 2016, this might be the plan for you.

Compare Your Options Check out the chart below to compare your Lucky Brand vision plan options.

What’s the Same? What’s Different?

• Administered by VSP

• Freedom to choose any eye doctor — you receive higher benefits if you use a VSP participating provider

• What’s covered — eye exams, prescription glasses, and contact lenses

• In-network benefit allowances for most eyeglass lens options

• Out-of-network benefit allowances for most prescription glasses and contact lenses

VSP Traditional Plan VSP Premium Plan

• Lowest per-paycheck price

• Highest exam and material copay

• Lowest in-network benefit allowance for contact lenses or glasses

• Wait two years for new frames

• Highest per-paycheck price

• Lowest exam and material copay

• Highest in-network benefit allowance for contact lenses or glasses

• Better benefits for lens options

• Wait one year for new frame


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What You’ll Pay for Vision Care VSP Traditional Vision Plan VSP Premium Vision Plan

In-Network Out-of-Network In-Network Out-of-Network

Eye Exam

(once every 12 months)

$20 copay Any expenses above $45

$10 copay Any expenses above $45

Materials $20 copay $10 copay

Eyeglass Lenses Once every 12 months Once every 12 months

Photochromic, anti-reflective, and progressive lenses covered at an additional cost

Any expenses above:

• $30 for single-vision lenses

• $50 for bifocal lenses

• $65 for trifocal/ progressive lenses

Includes photochromatic and anti-reflective lenses

Progressive lenses are covered at an additional cost

Any expenses above:

• $30 for single-vision lenses

• $50 for bifocal lenses

• $65 for trifocal/ progressive lenses

Eyeglass Frames Once every 24 months Once every 12 months

Material copay plus any costs above $130

Any costs above $70 Material copay plus any costs above $180

Any costs above $70

Contact Lenses

(once every 12 months from your last date of service, in place of eyeglasses)

Responsible for cost up to $60 for contact lens examination and fitting; for contact lenses, any costs above $130

Any costs above $105 allowance for contacts and contact exam and fitting

Responsible for cost up to $60 for contact lens examination and fitting; for contact lenses, any costs above $180

Any costs above $105 allowance for contacts and contact exam and fitting


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2016 Price TagsYou and Lucky Brand share the cost of your medical, dental, and vision coverage. While Lucky Brand pays the majority of the cost, you contribute as well. Here’s the amount that comes out of your paycheck on a pre-tax basis each pay period. (Pre-tax means that these costs are taken from your paycheck before federal and state taxes come out … that’s good news for you!) Remember, there are 26 pay periods per year.

Medical PricesLucky Choice PPO Lucky Choice

HDHPLucky Choice HDHP Saver


Hawaii Kaiser Permanente HMO (available to Hawaii residents only)

Employee Only $78.46 $43.85 $30.00 $64.62 Varies

Employee + Spouse

$161.54 $103.85 $73.85 $133.85 $106.15

Employee + Child(ren)

$147.69 $87.69 $62.31 $124.62 $92.31

Employee + Family

$244.62 $147.69 $103.85 $189.23 $156.92

2016 Price Tags

Medical Prices

Dental Prices

Vision Prices

Voluntary Life Insurance Prices

Voluntary AD&D Insurance Prices






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Dental PricesCigna Saver Dental Plan Cigna Traditional Dental Plan

Employee Only $6.00 $9.69

Employee + Spouse $13.85 $21.23

Employee + Child(ren) $10.15 $17.08

Employee + Family $20.77 $32.31

Vision PricesVSP Traditional Vision Plan VSP Premium Vision Plan

Employee Only $1.15 $3.00

Employee + Spouse $1.62 $4.27

Employee + Child(ren) $1.96 $5.31

Employee + Family $3.23 $8.31

2016 Price Tags

Medical Prices

Dental Prices

Vision Prices








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Voluntary Life Insurance PricesRates for associates and spouse/domestic partners are based on the associate’s age as of January 1, 2016.

Associate and Spouse/Domestic Partner Coverage

Age Band Monthly Rate (per $1,000 of coverage)

<20 $0.023

20-24 $0.023

25-29 $0.023

30-34 $0.030

35-39 $0.044

40-44 $0.060

45-49 $0.133

50-54 $0.208

55-59 $0.349

60-64 $0.582

65-69 $1.081

70-74 $1.081

75+ $1.081

Voluntary AD&D Insurance Prices Coverage Monthly Rate

(per $1,000 of coverage)

Associate $0.018

Family $0.018

Child $0.032

2016 Price Tags

Medical Prices

Dental Prices

Vision Prices








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Save Today with FSAsWant to get a discount on your health care or dependent care costs? Consider an FSA.

These plans let you save on taxes, by setting aside money from your paycheck to pay for certain expenses. But how does this tax break work? The money isn’t taxed when it goes into your FSA — it comes out of your paycheck before taxes are taken. This means you pay fewer taxes on your overall income, which means you get more of your money in your pocket! And, the FSA reimbursement isn’t taxed when you use your FSA funds. Discovery Benefits administers our FSAs (and HSAs, too). Learn more at www.discoverybenefits.com.

Lucky Brand offers three FSAs:

• Health Care FSA*

• Limited Purpose FSA*

• Dependent Care FSA

*If you enroll in the Lucky Choice HDHPs you can participate in the Limited Purpose FSA, but are not eligible to participate in a Health Care FSA.

The Not-So-“Flexible” Part of Your FSAs Leave it to the IRS. They mean well, but like with any other good tax break, FSAs sure have a lot of IRS rules … How much money you can set aside, when you can get it back, what you can claim, and on and on and on … But don’t worry. Once you get used to them, FSAs rock ‘cause they’ll save you money. We cover these rules in the plan descriptions in this section.

Domestic Partner ExpensesPlease note: Your domestic partner and children of your domestic partner must be considered federal tax dependents to be eligible dependents for purposes of your FSA, including the reimbursement of their expenses.

Save Today with FSAs

Health Care FSA

Limited Purpose FSA

Dependent Care FSA

• Who Can Open a Dependent

Care FSA

• Eligible Expenses







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Health Care FSASet aside up to $2,550 each year for eligible health care expenses like your deductible, coinsurance, or prescriptions drugs. These expenses can be for yourself or your eligible dependents — even if you’re not enrolled in a Lucky Brand health plan.

Remember: For most over-the-counter medications to be FSA-eligible, you must have a prescription before you buy them (that’s another IRS rule.)

Limited Purpose FSA (for Lucky Choice HDHP members)

If you enroll in the Lucky Choice HDHP or Lucky Choice HDHP Saver and you open an HSA, you aren’t eligible to participate in a Health Care FSA. However, you can participate in the Limited Purpose FSA to cover eligible dental and vision expenses. See Eligible Expenses for more details.

Here’s the Catch — Plan Carefully, or You Could Lose Money!At the end of the year, you’ll forfeit any money left in your FSA. These are IRS rules, and they’re no joke.

So plan carefully. Before you decide how much to put into an FSA for 2016:

• Look at the list of Eligible Expenses.

• Review your expenses for 2015 and consider any planned procedures for 2016.

Remember: Throughout the year, claim your eligible expenses ASAP to avoid that FSA money-ticking-like-a-time-bomb feeling!


Health Care FSA

Limited Purpose FSA

Dependent Care FSA


Care FSA


Got a Video? You bet. Click the link or scan the QR code below to learn more about the FSAs.







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Dependent Care FSASet aside up to $5,000 each year for eligible dependent care expenses. Designed for working parents, the Dependent Care FSA reimburses the cost of dependent child care and elder care. Because FSAs provide a tax advantage, a household is limited to $5,000 in reimbursement each year (yep, it’s another IRS rule). For example, if your spouse/domestic partner is contributing $5,000 with his or her employer, you’re at the household limit and can’t contribute under our plan.

Who Can Open a Dependent Care FSA?• Single working parents

• Families with two working spouses/domestic partners, or with one full-time student spouse/domestic partner

• Families with a disabled spouse/domestic partner who cannot care for himself/herself or their dependents

• Associates who claim dependents on their federal income tax return

• Associates with dependent children under age 13 who meet any of the above considerations

Claim Your FSA MoneyWhen it comes to making FSA claims, you’ve got options:

1. Use your Discovery Benefits debit card at your doctor’s office or pharmacy.

(This is easy. Do this!)

2. Pay with cash, check, or personal credit card, and then make your claim with the Discovery Benefits mobile app or Employee Portal www.discoverybenefits.com.

(This takes more effort. Use your debit card if you can!)

Save all receipts — or snap a picture — so you can verify your claims if you need to.

Submit all claims by March 31, 2017 after the plan year ends.


Health Care FSA

Limited Purpose FSA

Dependent Care FSA


Care FSA








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Eligible Expenses You can use the money in your Health Care FSA, Limited Purpose FSA, and Dependent Care FSA to cover the expenses outlined below during the year.

Eligible Health Care FSA expenses include:

Eligible Limited Purpose FSA expenses include:

Eligible Dependent Care FSA expenses include:

• Medical, dental, and vision plan deductibles

• Medical, dental, and vision plan copays and coinsurance

• Prescription drugs costs

• Medical items, equipment, supplies, or diagnostic devices (bandages, contact lens solution, crutches, or blood sugar test kits)

• Dental fillings and crowns

• Orthodontia (certain restrictions apply, contact the FSA administrator for more details)

• Hearing aids and exams

• Eye exams, prescription eyeglasses, and prescription contact lenses

• LASIK surgery

• Vision and dental plan deductibles

• Vision and dental plan copays and coinsurance

• Dental fillings and crowns

• Orthodontia (certain restrictions apply, contact the FSA administrator for more details)

• Hearing aids and exams

• Eye exams, prescription eyeglasses, and prescription contact lenses

• LASIK surgery

• At-home care for a child or adult you claim on your tax return

• The cost of a housekeeper who cares for a child or dependents and also performs household services

• Dependent care centers that meet state or local requirements and provide day care for more than six individuals

• Transportation furnished by a dependent care provider (does not cover field trips)

• Room and board expenses for a caregiver over and above normal household services

• Preschool and day camp (overnight camp is not eligible)

• Elder care for a tax dependent

Want to Spend Your FSA Dollars in All Kinds of Places? Learn more about eligible FSA expenses — check out www.irs.gov/publications/p502 and enjoy the ride.


Health Care FSA

Limited Purpose FSA

Dependent Care FSA


Care FSA


www.irs.gov/publications/p502






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Your Safety Nets: Life, Accident, and Disability InsuranceLife happens. Lucky Brand offers life, accident, and disability coverage to protect your income and give your family financial security when faced with accidents or even death.

• Lucky Brand provides basic benefits at no cost to you.

• For some plans, you can purchase more coverage for yourself and your family.

Cigna administers our life, accident, and disability insurance plans. Review your options below.


• Short-Term Disability Insurance

• Long-Term Disability Insurance

Life and Accident Insurance

• Basic Life and Accidental Death & Dismemberment (AD&D) Insurance

• Voluntary Life and AD&D Insurance

Questions About Your Disability, Life, and Accident Plans?Contact Cigna or go online to www.cigna.com.

Can I Get a Quote?You can find plan cost details for Voluntary Life and AD&D Insurance in 2016 Price Tags.

Your Safety Nets


• Short-Term Disability Benefits

• Long-Term Disability Benefits


• Basic Life and AD&D

• Voluntary Life and AD&D

www.cigna.com






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Disability Insurance Disability Insurance replaces a portion of your salary if you can no longer work, and it protects you from the financial burden of a limited income. Lucky Brand provides short-term disability and long-term disability benefits at no cost to you.

Short-Term Disability BenefitsThis plan pays weekly benefits during a short-term illness, injury, or pregnancy disability. However, it does not coordinate with Workers Compensation or Workplace Injuries. Your Lucky Brand disability benefits will coordinate with any federal or state disability benefits available, so your maximum payment won’t be higher than the amounts described below.

Short-Term Disability Coverage

Benefits Start Must be out from work for 8 or more days and under a doctor’s care

Weekly Benefit Up to 70% of your average wages earned

Benefits End After 26 weeks

Other paid leave benefits may include maternity, paternity, and military paid leaves. Contact the Benefits Department at [email protected] or by calling 844-282-8283.

Long-Term Disability BenefitsThis plan pays monthly benefits if you’re unable to work because of a covered disability. Your benefits usually start after short-term disability benefits end.

Long-Term Disability Coverage

Benefits Start After 180 days

Monthly Benefit 60% of your base salary, to a maximum of $15,000

Benefits End Differs by age

Your Safety Nets







mailto:Benefits%40luckybrand.com?subject=






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Life and Accident InsuranceReality check! What other sources of income would your family have if you were injured or died in an accident? This is your safety net. Life insurance pays a benefit in the event of your death, while AD&D insurance provides an additional benefit to you or your beneficiaries in the event of certain accidental losses or death. These benefits are reduced after you reach certain ages.

Don’t forget to take a closer look at your voluntary options to see if you need more coverage.

Basic Life and Accidental Death & Dismemberment (AD&D) Insurance Lucky Brand pays the full amount for your Basic Life and AD&D Insurance. Coverage is automatic — you don’t have to enroll in the plans. However, you do need to select a beneficiary. This is really important, because if you die, your beneficiaries will receive your insurance benefit amount.

Basic Life and AD&D Insurance Coverage Amounts

Basic Life Insurance 1 times your annual compensation, to a maximum of $1.2 million

Basic AD&D Insurance 1 times your annual compensation, to a maximum of $1.2 million

Your Safety Nets












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Layer It On — Voluntary Life and AD&D InsuranceLucky Brand provides basic coverage, but if you want more, you have options. You can buy another layer of protection for yourself and your family. If you purchase voluntary life or AD&D coverage for yourself, you can add coverage for your spouse or domestic partner and children, too.

Voluntary Life Insurance Coverage Amount

Associate 1 to 3 times your annual compensation, to a maximum of $1 million

Spouse/domestic partner 50% of your coverage, to a maximum of $500,000

Child(ren) to age 26 $5,000, $10,000 or $15,000 per child

Voluntary AD&D Insurance Coverage Amount

Associate 1 to 3 times your annual compensation, to a maximum of $1 million

Family 1 to 3 times your annual compensation, to a maximum of $1 million

Evidence of Insurability (EOI) You may be required to provide proof of your good health (the technical term is “evidence of insurability”), depending on the amount of voluntary life insurance you elect and when you elect it. No evidence of insurability is required for Voluntary AD&D Insurance.

Evidence of Insurability (EOI) Amount of Voluntary Life Insurance

Not required if you enroll when you are a new hire or during Open Enrollment. If you elect above 3 times your annual salary, you will need to answer a few simple health questions. Your responses will then be submitted to Cigna for approval.

Up to $250,000

If you are submitting a new or increased coverage request for you and your spouse/partner, your spouse/partner will need to answer a few simple health questions. Their responses will then be submitted for approval.

More than $30,000 for your spouse/partner

Not required. $5,000, $10,000 or $15,000 for your child(ren)

Prices depend on your age and the amount of coverage you choose. You’ll find them in 2016 Price Tags.

Your Safety Nets












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Your Future Is CallingHealth care benefits are all about your health, your well-being, and making smart choices today to cover yourself and your family. But health is just one part of your overall well-being.

While you’re spending time reviewing your insurance options why not spend a few extra minutes considering your financial well-being?

401(k) Plan Making the right decisions today can help set your financial well-being for 2016 and beyond. After all, it’s never too soon (or too late) to plan for your future financial needs. Lucky Brand’s 401(k) offers you a convenient way to save for your future.

EligibilityYou must be at least 21 years of age and have been with Lucky Brand for at least 6 months before you’re eligible to participate in the 401(k) plan.

ContributionsYou can contribute a percentage of your annual salary each pay period on a pre-tax basis. The yearly IRS maximum contribution limit for 2015 is $18,000 and an additional $6,000 if you are over the age of 50. Your selected contribution can be invested in a wide variety of financial investment options through Fidelity. These investments grow free of tax. Contributions and any earnings on contributions are tax-deferred until money is withdrawn.

Get Started TodayRegister your online account to select your investment schedule at www.401k.com. If you make no elections, your funds will be defaulted into a low risk, low return fund.

For the investment guide and guidance, contact Fidelity Investments at www.401k.com or call 800-835-5097.


401(k) Plan

• Eligibility

• Contributions

www.401k.com






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Extra Benefits

Employee Assistance Program (EAP)Stressed? Need help with a personal or work-related problem? You don’t need to “tough it out” or face these situations alone.

The Employee Assistance Program, or EAP, offers free, confidential and professional counseling for you and your extended family members. Did we say confidential? We did, and we mean it. Nothing you share is ever provided to Lucky Brand. It’s available 24/7 at no cost to you and includes:

• Up to three face-to-face sessions per year — assistance for grief, relationship challenges, parenting, substance abuse, and more

• Unlimited work/life benefits and personal services — referrals and resources for child care, parenting, financial planning, and more

• Websites, mobile apps, and other online tools.

For assistance, call ACI Specialty Benefits anytime at 800-932-0034 or visit http://www.affinity-online.com/

• Username: lucky

• Password: aci

Reach Out to the EAPSometimes, just talking about a problem with someone who has a fresh, unbiased view can help you cope with life’s challenges. Contact the EAP:

• 800-932-0034

• http://www.affinity-online.com/

Username: lucky

Password: aci

Extra Benefits

Employee Assistance Program

(EAP)

Commuter Benefits

Health Advocate

http://www.affinity-online.com/







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Commuter Benefits Your commute might be the worst part of your day, but make it a little better by getting a tax break! You can set aside pre-tax paycheck contributions to help you pay work-related commuting costs for public transportation. Whether you’re hopping on public transportation (like buses, trains, and metros), taking a vanpool, or stressed about how much it costs to park, be smart about your commute and start saving now.

Contribution LimitsYou can set aside pre-tax money from your paycheck up to the following limits:

Monthly parking costs: $250*

Monthly transit costs: $130

*As of this publication, the 2016 parking contribution limit is projected to increase to $255.

When you enroll for this benefit, you can then use Discovery Benefits’ portal to manage your plan, see your account history, and view your balance. Discovery Benefits will send you a debit card that you can use to pay for eligible commuter expenses, or you can set up an auto-pay feature on the portal. Keep in mind that you can only reimburse your commuter expenses through the plan. Visit www.discoverybenefits.com to set up your account.

Extra Benefits


(EAP)

Commuter Benefits

Health Advocate







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Health AdvocateYour health care can be complicated and overwhelming — get help navigating your medical insurance and your medical care with Health Advocate. In addition to helping you navigate your health care, Health Advocate can assistance your family members, including your spouse or partner, children, parents, and in-laws.

Health Advocate can help you:

• Find the right health care professionals (including non-covered or alternative health services) based on your needs, and estimate fees for services in your area

• Schedule appointments, and arrange for medical tests or special treatments

• Answer questions about diagnoses, test results, treatments, and medications (including cheaper, generic equivalents), and your medical bills

• Find in-home care, adult day care, group homes, assisted living, and long-term care

• Clarify or get help applying for Medicare, Medicare Supplement plans, and Medicaid

• Coordinate care among multiple providers

• Arrange transportation to appointments

Call 866-799-2725 to receive 24/7 support from Health Advocate.

Extra Benefits


(EAP)

Commuter Benefits

Health Advocate






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Sign Me Up!So you’ve checked out your benefits. Are you ready to enroll? Open Enrollment is your once-a-year opportunity to enroll in or make changes to your health and insurance benefit elections. If you don’t make changes to your coverage during this time, you may not be able to do so until next year (unless you experience a life change). Changes made during Open Enrollment go into effect on January 1, 2016.

What If I Don’t Enroll or Make Changes?You must take action during Open Enrollment if you want medical, dental, or vision coverage in 2016. If you do not enroll before the deadline on October 31, 2015, you will not have medical, dental, or vision coverage in 2016. You will only have company-provided benefits, such as disability, and basic life and AD&D coverage.

Any changes to your benefit price tags will begin with your first paycheck in January 2016.

Get Decision HelpMaking enrollment decisions can be tough, which is why our Plan Cost Estimator Tool makes it easy for you to find the plan that’s right.



Sign Me Up!

Who’s Eligible

• Dependent Eligibility

Enroll Now!

Continued








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Who’s Eligible for Lucky Brand Coverage?You’re eligible for health and welfare benefits if you’re a full-time associate working at least 30 hours per week. Associates living in Hawaii are eligible if they work at least 20 hours per week.

Dependent EligibilityIf you’re eligible for benefits coverage, you can also enroll your eligible dependents. Eligible dependents include your:

• Legal spouse

• Domestic partner

• Children up to age 26 including children of your spouse or domestic partner, subject to carrier guidelines

• Dependent children who are unmarried, dependent on you or your spouse/domestic partner as a result of mental or physical incapacity, and who become disabled before reaching age 26.

Domestic Partner Coverage The IRS does not recognize domestic partners as legal dependents for purposes of tax reporting. For this reason, Lucky Brand must report the value (employer subsidy) of medical benefits. Employee contributions for domestic partner benefits are made after tax. The employer contributions of health and/or dental benefits must be included in the employee’s taxable income for federal and state withholding for any state other than California for registered and married domestic partners.

Life Change EventsWe understand when a big change happens in your life, your benefits can be the last thing on your mind. When these events happen, however, you’ll need to adjust your coverage within 31 days. Life change events include:

• Birth or adoption of a child

• Marriage or divorce

• Death

• Loss of benefits under a spouse/domestic partner’s plan.

To make changes or to get a full list of qualifying life events, go to Workday.

Sign Me Up!

Who’s Eligible


Enroll Now!

http://www.myworkday.com/luckybrand






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Enroll Now!Ready to enroll?

Review the Online Open Enrollment Video, which provides a step-by step guide to signing up for your benefits in Workday. When you’re ready, log in at www.myworkday.com/luckybrand and follow the instructions from the video to enroll for your benefits.

Sign Me Up!

Who’s Eligible


Enroll Now!

https://login.microsoftonline.com/login.srf?wa=wsignin1.0&rpsnv=4&ct=1444930237&rver=6.1.6206.0&wp=MBI&wreply=https%3A%2F%2Fluckybrand.sharepoint.com%2F_forms%2Fdefault.aspx%3Fapr%3D1&lc=1033&id=500046

www.myworkday.com/luckybrand






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Have Questions?Benefits Provider Phone Number Website Group Number

Medical UHC Lucky Choice PPO

UHC Lucky Choice HDHP

UHC Lucky Choice HDHP Saver

888-638-0106 www.myuhc.com 0901926

California Kaiser Permanente HMO

800-278-3296

www.kp.org

231845 7661

Hawaii Kaiser Permanente HMO

808-432-5955 7661

Health Savings Account (HSA)

Discovery Benefits 866-451-3399 www.discoverybenefits.com N/A

Dental Cigna 800-244-6224 www.cigna.com 3339186Vision VSP 800-877-7195 www.vsp.com 300042268FSA Plans Discovery Benefits 866-451-3399 www.discoverybenefits.com N/AEAP ACI Specialty Benefits 800-932-0034 http://www.affinity-online.com/ N/ALife, Accident, and Disability Insurance

Cigna 800-362-4462 www.cigna.com Life: FLX966928

AD&D: OK968435

STD: SHD962722

LTD: LK964750401(k) Fidelity 800-835-5097 www.401k.com 08614Commuter Benefit

Discovery Benefits 866-451-3399 www.discoverybenefits.com N/A

Health Advocate

Cigna 866-799-2725 N/A N/A

Questions?Contact the Benefits Department at 844-282-8283 or via email at [email protected].

Questions

www.myuhc.com

www.kp.org


www.cigna.com

www.vsp.com



www.cigna.com

www.401k.com


mailto:benefits%40luckybrand.com?subject=






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Required Federal Annual Notices Review your required federal annual notices and the Summary Annual Report (SAR) of Lucky Brand benefits.

The benefit summaries included in this guide are provided for informational purposes only. This is not a Summary Plan Description (SPD). The descriptions of your Lucky Brand associate benefits included in this guide are intended only as brief summaries and are not binding. In the event of a conflict between information provided in this summary and the plan documents, the plan documents determine the benefits that will be provided.

For further explanation regarding any of Lucky Brand’s benefit plans or associate programs, please refer to the plan document, policy, or SPD. SPDs describe the provisions and features of a benefit plan, including eligibility, coverage, associate rights, and appeals procedures. SPDs for all plans are posted on Workday ESS, and Lucky Intranet.

Annual Notices



%20luckybrand.sharepoint.com/HR






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Words to KnowWe know all these insurance and health care terms can sound like a bunch of mumbo-jumbo. But, take a minute to get a handle on the jargon — we promise it will help you feel more comfortable with your coverage, and it may even help you make the most of your plans!

Coinsurance — For plans with a deductible, this is the amount you pay for a covered service or supply. The coinsurance rate is usually expressed as a percentage. For example, if the claim is paid at 80%, then the coinsurance you pay is the remaining 20%.

Copay — The fixed dollar amount you pay for a covered service or supply (such as a doctor’s office visit or a prescription) at the time you receive it.

Deductible — The amount that you pay each calendar year toward medical and dental expenses before the plan begins paying benefits (your medical and dental plans have separate deductibles).

HMO — Health Maintenance Organizations (HMOs) are health plans that help manage and coordinate your care. HMOs provide care through a network of doctors, hospitals, and laboratories. HMOs require you to select a primary care physician (PCP) or a medical group for you and your covered family members. All of your treatment and care must be coordinated by your PCP/medical group, except in a life-threatening emergency.

Maximum Allowed Amount — The typical charge for a medical and dental product or service in your geographic area, as determined by the insurance industry. When receiving care from out-of-network providers, the amount the plan pays for covered services is based on the maximum allowed amount. If an out-of-network provider charges more than the maximum allowed amount, you may have to pay the difference. The maximum allowed amount does not count toward the deductible or the annual out-of-pocket maximum. (This is called balance billing.) Note: The maximum allowed amount does not apply to in-network services under the Kaiser Permanente HMO plans because it uses in-network providers exclusively.

Words to Know

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Out-of-Pocket Maximum — The most you are required to pay for medical care in a plan year. Once you have met the out-of-pocket maximum, most services will be paid at 100% for the rest of the plan year. Note: Amounts above the maximum allowed amounts for out-of-network services and non-covered expenses are not subject to the out-of-pocket maximum.

PPO — Preferred Provider Organizations (PPOs) are health plans that provide care through a group of doctors, hospitals, laboratories, and other health care providers who participate in a network and agree to accept discounted rates for members who use the network. If you use in-network providers, the cost of health care services are lower. With a PPO, you can receive coverage for services from out-of-network providers, but you will pay more.

Annual Notices

In addition to a healthy lifestyle, preventive medications can helppeople avoid many illnesses and conditions. A consumer-directedhealth (CDH) plan that includes preventive medications can helpsupport the goal of ongoing good health.

This list provides examples of commonly prescribed preventive medications. The medications are categorized based on the medicalconditions that they are used to prevent. This is not an all-inclusive list;only examples of medicines in each category are listed. Coverage priorto the deductible being met may not be provided for every dosageform of a listed medication.

This list does not indicate coverage. Please check with your planadministrator and/or benefit information materials if you have questions on coverage. Your cost share will be determined by yourplan’s drug coverage and formulary plan.

This list is periodically reviewed and updated to ensure that the drugslisted meet the criteria for inclusion.

Medications on this list that are not covered under yourplan are not eligible for the preventive medication program.

Preventive medications list

PDL6014D

ASTHMA/COPDACCOLATEZAFIRLUKAST

ANORO ELLIPTAARNUITY ELLIPTAASMANEX HFABREO ELLIPTACOMBIVENT RESPIMAT DULERAGASTROCROMCROMOLYN SODIUM

INCRUSE ELLIPTAPROAIR HFA, VENTOLIN HFAPULMICORTBUDESONIDE

QVARSEREVENT DISKUSSINGULAIRMONTELUKAST

SPIRIVASTRIVERDI RESPIMATSYMBICORTZYFLO CRRESPIRATORY SUPPLIESNEBULIZERS AND INHALER ASSISTIVEDEVICES

BONE DISEASE AND FRACTURESACTONELRISEDRONATE

BONIVAIBANDRONATE

EVISTARALOXIFENE

FOSAMAX, FOSAMAX PLUS DALENDRONATE

RECLASTZOLEDRONIC ACID

CAVITIESSTANNOUS FLUORIDE PASTE AND RINSE

CLINPRO, PHOS-FLURSODIUM FLUORIDE PASTE AND RINSE

COLONOSCOPY PREPARATIONGOLYTELY, NULYTELY, MOVIPREPPOLYETHYLENE GLYCOL

OSMOPREP, SUPREPPREPOPIKDIABETES

INSULINS:

AFREZZAHUMALOG, 50/50, 75/25HUMULINLANTUS, LANTUS SOLOSTARLEVEMIRTOUJEO SOLOSTARNON-INSULIN MEDICINES:

ACTOS, DUETACT, ACTOPLUS METPIOGLITAZONE AND COMBINATIONS

AMARYLGLIMEPIRIDE

AVANDIAAVANDAMET, AVANDARYLBYETTADIABETA, GLYNASE, GLUCOVANCEGLYBURIDE AND COMBINATIONS

DIABETIC SUPPLIES TEST STRIPS, SYRINGES, NEEDLES ANDLANCETS

FORTAMET, GLUCOPHAGEMETFORMIN

GLUCOTROLGLIPIZIDE AND COMBINATIONS

GLYXAMBI

Preventive Medications List

INVOKANAJANUVIA, JANUMETJARDIANCEJENTADUETOPRANDINREPAGLINIDE

STARLIXNATEGLINIDE

SYMLINPENTRADJENTATRULICITY XIGDUO XR

HEART DISEASE AND STROKE

BLOOD THINNER MEDICINES: ASPIRIN, 81 MG OR 325 MGAGGRENOX ASPIRIN-DIPYRIDAMOLE ER

BRILINTACOUMADINWARFARIN

EFFIENT ELIQUISPERSANTINEDIPYRIDAMOLE

PLAVIXCLOPIDOGREL

PRADAXASAVAYSATICLIDTICLOPIDINE

XARELTOZONTIVITYCHOLESTEROL LOWERING MEDICINES HMG-COA REDUCTASEINHIBITORS:

CRESTORLIPITORATORVASTATIN

MEVACORLOVASTATIN

PRAVACHOLPRAVASTATIN

ZOCORSIMVASTATIN

OTHER AGENTS: ADVICORCOLESTIDCOLESTIPOL

LOPIDGEMFIBROZIL

PREVALITE, QUESTRANCHOLESTYRAMINE

SIMCORTRICOR, ANTARAFENOFIBRATE

TRILIPIX DRFENOFIBRIC ACID

VYNTORINWELCHOLZETIAHIGH BLOOD PRESSURE

ACE INHIBITORS:

ACCUPRILQUINAPRIL

LOTENSINBENAZEPRIL

PRINIVIL, ZESTRILLISINOPRIL

VASOTECENALAPRIL


ACE INHIBITORS/DIURETIC COMBINATIONS:

ACCURETICQUINAPRIL/HCTZ

LOTENSIN HCT BENAZEPRIL/HCTZ

VASERETICENALAPRIL/HCTZ

ZESTORETICLISINOPRIL/HCTZ

ANGIOTENSIN II RECEPTORANTAGONISTS:

ATACAND CANDESARTAN

AVAPRO IRBESARTAN

COZAAR LOSARTAN

DIOVAN VALSARTAN

ANGIOTENSIN II RECEPTORANTAGONISTS/ DIURETICCOMBINATIONS:

ATACAND HCT CANDESARTAN/HCTZ

AVALIDEIRBESARTAN/HCTZ

DIOVAN HCTVALSARTAN/HCTZ

HYZAARLOSARTAN/HCTZ

BETA BLOCKERS:

BYSTOLICINDERAL LA, INNOPRAN XLPROPRANOLOL

TENORMIN ATENOLOL

TOPROL XLMETOPROLOL

ZEBETA BISOPROLOL

BETA BLOCKERS/DIURETIC COMBINATIONS:

PROPRANOLOL/HCTZCORZIDENADOLOL/BENDROFLUMETHIAZIDE

LOPRESSOR HCT METOPROLOL/HCTZ

TENORETICATENOLOL/CHLORTHALIDONE

ZIAC BISOPROLOL/HCTZ

CALCIUM CHANNEL BLOCKERS:

ADALAT CC, PROCARDIA XLNIFEDIPINE

CALAN, VERELANVERAPAMIL

CARDIZEM LA, TIAZAC ER DILTIAZEM

NORVASCAMLODIPINE

SULAR ERNISOLDIPINE

DIURETICS:CHLORTHALIDONEHYDROCHLOROTHIAZIDEINDAPAMIDEMETOLAZONE

OTHER HIGH BLOOD PRESSURE MEDICINE COMBINATIONS:

AZORCADUETAMLODIPINE/ATORVASTATIN


EXFORGE HCT AMLODIPINE/VALSARTAN/HCTZ

LOTRELAMLODIPINE/BENAZEPRIL

TARKATRANDOLAPRIL/VERAPAMIL

TRANDOLAPRILTRIBENZORTWYNSTAAMLODIPINE/TELMISARTAN

RESPIRATORY SYNCYTIAL VIRUSSYNAGIS

MALARIACHLOROQUINEMEFLOQUINEPRIMAQUINEMALARONEATOVAQUONE/PROGUANIL

OBESITYDIETHYLPROPIONADIPEX-PPHENTERMINE

BELVIQBONTRIL PDMPHENDIMETRAZINE

CONTRAVESAXENDAXENICAL

SMOKING-CESSATION *CHANTIXNICOTROL/NICODERM CQNICOTINE PRODUCTS

ZYBANBUPROPION SR 150MG

IMMUNIZATION: *DIPHTHERIA, PERTUSSIS, TETANUS,HAEMOPHILUS INFLUENZAE B, HEPATITIS A AND B, JE-VAX, TYPHIM,VARICELLA, ZOSTER, HUMANPAPILLOMAVIRUS, INFLUENZA,MEASLES, MENINGOCOCCAL,MUMPS, PNEUMOCOCCAL,POLIOVIRUS, ROTAVIRUS, RUBELLA

VITAMINS OR MINERALSFOLIC ACID*PRENATAL VITAMINSPEDIATRIC MULTIVITAMINS WITH FLUORIDE*


*Please note that some of these medications are also subject to the Affordable CareAct (ACA) and may be covered by your plan at 100%.

Notes

Express Scripts manages your prescription benefit for your employer, plan sponsor, or health plan.

*0000000PDL6014D**0000000PDL6014D*

Express Scripts manages your prescription benefit for youremployer, plan sponsor, or health plan. For specific questions oncoverage, please call the phone number on your ID card or visitour website Express-Scripts.com. Please note: Brand names are shown in italics in each category.If generic is available, it is listed under the brand name.

All rights in the product names of all third-party products appearinghere, whether or not appearing with the trademark symbol, belongexclusively to their respective owners.

PDL6014D 8.15 OPTION 2CRP15_1293

1

Lucky Choice HDHP User Toolkit

A New Way to Look at Health CareOur two High Deductible Health Plans (HDHPs), the Lucky Choice HDHP and the Lucky Choice HDHP Saver, are not your average plans. Unlike the Lucky Choice PPO, these plans have relatively high annual deductibles. But don’t let that scare you away. As a trade-off for the higher deductibles, you get access to a Health Savings Account (HSA). The HSA is a tax-advantaged savings account where you can save money to pay for eligible medical expenses. And as a bonus, for this first year, Lucky Brand also puts money into your HSA as long as you make a starter contribution. And it gets better! Your HSA money rolls over from year to year, and any balance, including Lucky Brand’s contribution, go with you if you leave Lucky Brand.

This guide is filled with tips to help you take advantage of money-saving opportunities and other health care resources that are available through both HDHPs. Find out how you can use these plans to best meet your health care needs.

How the HDHPs Work

Why You Should Consider the HDHPs

1 Comprehensive coverage. The HDHPs cover the same services as the Lucky Choice PPO plan, and also have the same network of providers. From office visits and hospital care to prescription drugs and more, you know you have the coverage you need.

2 Lower rates. Your paycheck contributions for both of the HDHPs are lower than those for the Lucky Choice PPO. You pay the lowest rate with the Lucky Choice HDHP Saver plan.

3 Ability to save for health care expenses — now and in the future. With the HDHPs, you can establish an account that allows you to save for health care expenses tax-free (known as a Health Savings Account, or HSA). And, when you enroll in an HDHP, Lucky Brand will deposit FREE MONEY into your HSA for the first year to help you cover your medical costs, as long as you contribute a little bit of starter money first.

PARt 1

PPO Medical Plan with network providers,

comprehensive coverage, and an annual deductible

PARt 2


that lets you pay for expenses tax-free

Lucky Choice HDHPs

Look good. Feel good. Do good. Lead a Lucky life.

Part 1: PPO Medical PlanYou have two Lucky Brand plans to choose from: the Lucky Choice HDHP and the Lucky Choice HDHP Saver. It’s up to you to compare the plans and choose the one that’s right for you!

What’s Different?The HDHPs operate in the same way. So, what’s the difference? It’s the amount you pay. With the Lucky Choice HDHP Saver plan, you pay lower payroll contributions, but the deductible and out-of- pocket maximum amounts are higher, and you’ll pay more coinsurance for certain medical services. See Which Plan Is Right for You on page 6 for more details

What’s the Same?Both HDHPs have four basic components:

1 Free in-network preventive care. To emphasize the importance of wellness, your preventive care is fully covered under either plan, with no deductible and no coinsurance, as long as you receive this care from in-network providers. This includes annual physicals, well-child checkups, immunizations, flu shots, well-woman exams, mammograms, and other cancer screenings.

2 Deductible. You pay for your initial (non-preventive) medical costs until you meet your annual deductible. To help offset the deductible, you can save tax-free money in your Health Savings Account (HSA) to help pay for these out-of-pocket costs.

3 Coinsurance. Once the deductible is met, you and the medical plan share any further health care costs until you meet your out-of-pocket maximum. This is known as coinsurance.

4 Out-of-pocket maximum. The medical plan limits the total amount you pay each year for medical care. Once you meet your out-of-pocket maximum, the plan pays 100% of your eligible, in-network expenses for the remainder of the year.

You can find a detailed summary of benefits in your 2016 Benefits Guide at luckybrand.sharepoint.com/HR.

2

luckybrand.sharepoint.com/HR

Part 2: the Health Savings Account … Helping Cover the Costs of Health Care

A Health Savings Account (HSA) works in partnership with your HDHP — no matter which one you choose. It’s a tax-advantaged savings account where you and Lucky Brand contribute money to cover the costs of your health care. The money in your HSA is federally tax-free — contributions are made on a pre-tax basis, and you aren’t taxed when eligible expenses are reimbursed.

Key Features4 Lucky Brand will deposit money into your HSA for this first year when you

enroll in either HDHP. This is free money you can use to pay any eligible expenses. You must make your own minimum contribution to your HSA in order to receive Lucky Brand’s contribution. Lucky Brand’s contributions vary depending on the plan you choose and whether you cover dependents. See Page 4 for amounts.

4 All the money in your HSA is yours to keep, including any interest or earnings.

4 You never lose the money in your HSA.

4 You can use the money now or roll over unused money to cover future expenses.

4 You can take the account with you if you leave Lucky Brand and even use the money to cover health care costs during retirement.

In-Network Preventive Care

The plan pays 100%.

Deductible

You pay 100%. Once you meet the

deductible, then coinsurance kicks in.

Coinsurance

You and the plan share a percentage of the cost until you

meet the out-of-pocket maximum.

Out-of-Pocket Maximum

Once you reach this, the plan pays 100% of in-network costs for the remainder of the

calendar year.


Contributions to the Health Savings Account — from Lucky Brand and you — can cover your

deductible and coinsurance.

HDHPs and the HSA: How They Work Together

3

Digital DigestLearn about the HSA’s most important features within a few minutes — watch the video by clicking the link.


4

Contribution Limits Contributions to your HSA come from two sources — you and Lucky Brand. All the money in your account is yours to spend on health care or save. The IRS limits the amount you can put into your HSA each year:

• If you have “Individual” coverage: Up to $3,350• If you have “Family” coverage: Up to $6,750

The table below shows how much Lucky Brand will contribute based on the plan you choose, and the total contribution you can make, up to the IRS limit.

tier LevelWhen you contribute …

then Lucky Brand will also contribute …

So, you can contribute this additional amount ...

Lucky Choice HDHP

Individual $250 $500 $2,600

Family $500 $1,000 $5,250


Individual $250 $250 $2,850

Family $500 $500 $5,750

StARt It BUILD It USE It GROW It KEEP It

• Once you elect one of the HDHPs, you can set up an HSA so you can start contributing as of January 1, 2016.

• Visit www.discoverybenefits.com to create your account. You’ll need to accept the service terms in order to begin receiving your or Lucky Brand’s contributions.

• You contribute to your HSA, up to IRS limits, through pre-tax payroll contributions.

• Lucky Brand will contribute money to your HSA if you make a minimum contribution.

• You can change the amount you contribute anytime.

• You can use the money in your HSA to pay for covered health care — you even get an HSA debit card to use at the point of service.

• Withdrawals from your HSA for qualified medical expenses are tax-free!

• You don’t need to provide receipts for reimbursement — you only need to save them for tax purposes.

• Unused money in your account will roll over to the next year.

• Your account will earn interest and grow over time.

• Once your account reaches $1,000, you may invest your HSA dollars in available mutual funds.

• Any interest and other investment earnings are tax-free and yours to keep.

• You always own the money in your HSA.

• You can take the account with you if you leave Lucky Brand.

How an HSA Works

Learn more about using your Health Savings Account (HSA) at www.discoverybenefits.com. Please note: If you cover a domestic partner under one of the Lucky Choice HDHPs, it’s important to note that your

domestic partner’s health care expenses aren’t eligible for reimbursement from your HSA, unless he or she is

considered a federally-recognized spouse or tax dependent.

HSA Facts100%How much of your unused HSA balance rolls over year to year.

100%How much of your unused HSA balance you can take with you if you leave Lucky Brand.

100%How much of the money in your HSA grows tax-free.

$0Taxes you pay on the money you contribute to the HSA or withdraw for qualified expenses (subject to state tax regulations).





Six Important HSA Rules The HSA has many benefits. But, there are some important rules to remember:

1 Annual LimitsThe IRS limits the amount you can contribute to an HSA each year.

These limits may change each year. It’s your responsibility to ensure your contributions don’t exceed the annual limit. Tax penalties may apply on excess contributions. You should consult your personal tax advisor for questions regarding your HSA and filing your tax returns.

2 Expenses You Can Pay through Your HSA You can use your HSA for out-of-pocket expenses that would generally qualify for the medical, dental, and vision expenses income tax deduction:

• Deductibles • Office visits• Prescription drugs • Hospital stays and lab work

• Speech/occupational/physical therapies• Dental care• Vision care.

Money that you put in an HSA can also be used for over-the-counter medicine, Band-aids, prescription drug costs, and a variety of other expenses. (Note: You need a prescription to be able to reimburse expenses for over-the-counter items on a tax-free basis.)

For a complete list of eligible expenses, go to www.discoverybenefits.com or www.irs.gov/publications/p502.

3 Domestic PartnersThe IRS doesn’t consider a domestic partner to be a spouse under federal tax law, regardless of state law exceptions. Therefore, you can’t withdraw funds tax-free to pay for your domestic partner’s qualified expenses, unless your domestic partner is a federally-recognized spouse or “qualified tax dependent” as defined by the IRS. However, your domestic partner can set up his or her own HSA to cover eligible expenses. If you both set up HSAs, you can each contribute up to the maximum amount allowed each year by the IRS.

4 Flexible Spending Account ParticipationIf you enroll in either of the HDHPs, you cannot enroll in the Health Care Flexible Spending Account (FSA). However, you can enroll for the Limited Purpose FSA provided through Lucky Brand, which expands the amount you can save pre-tax on eligible dental and vision expenses — you can contribute up to $2,550 in a Limited Purpose FSA.

5 Not Everyone Can Open an HSAAll benefit eligible employees can enroll in the Lucky Choice HDHP or Lucky Choice HDHP Saver. However, you aren’t eligible to open an HSA if you are:

• Enrolled in another medical plan (such as your spouse’s/domestic partner’s plan), unless it is a qualified high deductible health plan

• Enrolled in Medicare • Eligible to be claimed as a dependent on another individual’s tax return• Are not a U.S. resident • A veteran and have received veterans’ benefits within the last three months• Active military

6 When you enroll for your HSA, it is automatically opened by Discovery Benefits. However, you must visit their website and accept the service terms before your account is officially established. Visit www.discoverybenefits.com to complete the final account setup steps and to create your personal login.

5


www.irs.gov/publications/p502


Which Plan Is Right for You?The HDHPs make purchasing health care like buying any other product or service. You determine what kind of care you receive, how much, where, and why. This can save you money — while increasing the quality of your care. Find out which plan is right for you by using the chart below. You can also use the Plan Cost Estimator Tool available at www.pcestimator.com (use login “LuckyBrands2016” with password “Benefits2016”).

Lucky Choice HDHP Lucky Choice HDHP Saver

Paycheck Contributions Higher – but lower than Lucky Choice PPO and HMO plans

Lower – in fact, the lowest of all the Lucky Brand medical plans

HSA Contribution

(Please note: Lucky Brand’s contribution is dependent on you making the minimum contribution to the account as well)

Lower – Lucky Brand contributes $500 for individual coverage, and $1,000 for family coverage

Higher – Lucky Brand contributes $250 for individual coverage, and $500 for family coverage

Preventive Care Same – Both plans cover preventive care for FREE

Preventive Prescription Drugs Same – For both plans, your preventive prescription drugs are covered with coinsurance (meaning you only pay 20% or 30% of the cost, depending on the plan), without you having to meet the deductible first

Deductible Lower – You must reach the $1,500 individual deductible or $3,000 family deductible before the plan will begin to help pay for your care

Higher – You must reach the $2,500 individual deductible or $5,000 family deductible before the plan will begin to help pay for your care

Coinsurance Higher – Once you reach the deductible, the plan pays 80% of the cost of your care; you pay the other 20%.

Lower – Once you reach the deductible, the plan pays 70% of the cost of your care; you pay the other 30%.

Choice of Providers Same – Both plans use the same network, and you can see any provider you want (though we recommend staying inside the network …

it’s cheaper that way!). The network name varies by your location:

• Inside California: Select Plus network• Outside California: Choice Plus network

Download the Discover Benefits Mobile AppThe app allows you to upload receipts, check your balances, view final filing dates, access claim detail, contact customer service, report a lost or stolen debit card, reset your password, and even file a claim.

6




www.pcestimator.com

www.pcestimator.com

Additional InformationWe know you’ve probably got questions. Here is a sample just to get you started. If you have more, see Discovery Benefit’s FAQs at www.discoverybenefits.com, or reach out to Lucky Brand’s Benefits Department at [email protected].

Fact or Fiction?

the HDHPs have high deductibles. that means I can’t afford this plan.

False. The deductibles for these plans are high, which is why Lucky Brand will contribute money to your HSA as long as you make the minimum contribution. The high deductible of these plans is also offset by lower paycheck contributions and by tax savings through your HSA contributions.

If I have a catastrophic health event or chronic condition, I’m going to have to pay most of my medical costs myself.

False. Remember, a portion of your deductible will be covered by Lucky Brand’s contribution to your HSA. After that, you’ve got a financial safety net to catch you, called the out-of-pocket maximum. Once you hit that amount, the plan pays 100% for the rest of the year for all covered services and supplies.

The out-of-pocket maximums are:

Lucky Choice HDHP

• $3,000 for individual coverage

• $6,000 for family coverage


• $4,500 for individual coverage

• $6,850 for family coverage

And keep in mind, the safety net includes the annual deductible.

Note: The out-of-pocket maximum is higher for out-of-network providers and doesn’t cover any expenses that are not considered “Reasonable and Customary” by your plan.

Health Savings Accounts are hard to use.

False. The HSA works just like a personal bank account.

• The account is in your name and you own it. You’ll be able to use the money in it to pay medical bills, and it’s your responsibility to manage the account.

• It’s easy to pay medical bills with your HSA: Just swipe your debit card. You can use your debit card for direct payment at a doctor’s office, pharmacy, or any health care facility that accepts the card.

• You don’t have to pay with your HSA. It’s always your choice: You can pay from your pocket and save your HSA money for later — whether that’s later in the year, next year, or to pay for health care costs in retirement.

• Some people like to use this option for smaller expenses, so their account builds up over time. And, any amount left in your account at the end of the plan year will roll over to the next plan year.

Enrolling in the HDHPs can help me save for retirement.

true. Your HSA can serve as a great retirement savings tool. You can save money in hour HSA now — the company’s contribution and yours, if you choose to contribute — and us it when you retire.

Remember, if you don’t use the money in your HSA, it doesn’t just sit there. The account builds through contributions, interest, and investment growth. And, it rolls over from year to year.

Since you own the account, you get to keep it — even if you leave the company or retire, the HSA funds are yours. And that means long-term savings.

My HSA election is final after Open Enrollment ends.

False. You can change the amount you contribute to your HSA at any time.

You can even choose to make post-tax contributions to your HSA with a personal check.

7


mailto:Benefits%40luckybrand.com?subject=

8

Make the Most of Your Pre-tax DollarsWith the HDHPs, you’re in full control of your health care purchasing. Here are some tips to make the most of your coverage.

tIP #1:

Calculate the difference

in premiums you’re paying and save it in your HSA: For

example, Employee Only coverage on the Lucky Choice PPO is $78.46 per paycheck and the Lucky Choice HDHP Saver is $30.00

per paycheck. The difference is $48.46 per pay period. Make that

your HSA contribution, and at the end of the first year you’ll have saved $1,259.96, not

including Lucky Brand’s contribution!

tIP #2:

Front-end load your HSA: With an HSA,

you can add, remove, or change the amount

you’re contributing at anytime (unlike

the FSA where your elections cannot be changed midyear

unless you experience a qualifying life change event). If

you can, you could contribute a larger amount out of your first few paychecks

in the year to quickly build a balance

for immediate or unforeseen expenses,

then reduce the amount for the

remainder of the year.

tIP #3:

Reimburse yourself: Say you don’t have enough in your HSA early on to pay for a medical expense. You can pay for the

expense out-of-pocket and later pay yourself back from your HSA.

tIP #4:

Keep receipts: Unlike an FSA where you

have to demonstrate expenses were

eligible prior to being reimbursed, with the HSA it’s your

responsibility to track and maintain records

of how your HSA funds were used. You’ll need these

records in the event you are ever audited

by the IRS.

This guide provides general benefit plan information only. For specific details, conditions and exclusions, please refer to the official Summary Plan Descriptions (SPD). If there is a discrepancy between this guide and an official SPD, the official documents will govern.

SUMMARYANNUALREPORTfor

LuckyBrandHealth&WelfareBenefitsPlan

This is a summary of the annual report of the Lucky Brand Health & Welfare Benefits Plan, EIN95-4363823, Plan No. 501, for period February 3, 2014 through December 31, 2014. The annualreport has been filed with the Employee Benefits Security Administration, U.S. Department ofLabor, as required under the Employee Retirement Income Security Act of 1974 (ERISA).

InsuranceInformation

The plan has contracts with ACI Specialty Benefits, Aetna Life Insurance Co., Kaiser FoundationHealth Plan Inc, Kaiser Foundation Health Plan of Hawaii, and Vision Service Plan to pay certainhealth, vision, life insurance, long-term disability, accidental death and dismemberment, andemployee assistance program claims incurred under the terms of the plan. The total premiumspaid for the plan year ending December 31, 2014 were $631,063.

YourRightstoAdditionalInformation

You have the right to receive a copy of the full annual report, or any part thereof, on request.The items listed below are included in that report:

· insurance information, including sales commissions paid by insurance carriers;

To obtain a copy of the full annual report, or any part thereof, write the office of Lucky Brand at540 S. Santa Fe Avenue, Los Angeles, CA 90013, or call at (213) 443-5700. The charge to covercopying costs will not exceed $.25 per page.

You also have the legally protected right to examine the annual report at the main office of theplan ( Lucky Brand, 540 S. Santa Fe Avenue, Los Angeles, CA 90013) and at the U.S. Departmentof Labor in Washington, D.C., or to obtain a copy from the U.S. Department of Labor uponpayment of copying costs. Requests to the Department should be addressed to: PublicDisclosure Room, Room N1513, Employee Benefits Security Administration, U.S. Department ofLabor, 200 Constitution Avenue, N.W., Washington, D.C. 20210.

1

Required Federal Legal Notices

Notice of Special Enrollment Rights for Health Coverage Special enrollment events allow you and your eligible dependents to enroll for health coverage outside the

Open Enrollment period under certain circumstances if you lose eligibility for other coverage, become

eligible for state premium assistance under Medicaid or the Children’s Health Insurance Program (CHIP), or

acquire newly eligible dependents. This is required under the Health Insurance Portability and

Accountability Act (HIPAA).

If you decline enrollment in a Lucky Brand medical plan for you or your dependents (including your

spouse/domestic partner) because of other health insurance or group health plan coverage, you or your

dependents may be able to enroll in a Lucky Brand medical plan without waiting for the next Open

Enrollment period if you:

Lose other health insurance or group health plan coverage. You must request enrollment within 31 days

after the loss of other coverage;

Gain a new dependent as a result of marriage, birth, adoption, or placement for adoption. You must

request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption; or

Lose Medicaid or Children’s Health Insurance Program (CHIP) coverage because you are no longer

eligible. You must request enrollment within 60 days after the loss of such coverage.

If you request a change due to a special enrollment event within the 31-day timeframe, coverage will be

effective the date of birth, adoption or placement for adoption. For all other events, coverage will be

effective the first of the month following your request for enrollment. In addition, you may enroll in a Lucky

Brand medical plan if you become eligible for a state premium assistance program under Medicaid or CHIP.

You must request enrollment within 60 days after you gain such coverage. You must request enrollment

within 60 days after you gain eligibility for medical plan coverage. If you request this change, coverage will

be effective the first of the month following your request for enrollment. Specific restrictions may apply,

depending on federal and state law.

Important! If your dependent becomes eligible for a special enrollment right, you may add the dependent to

your current coverage or change to another health option.

Primary Care Provider Designation for Kaiser Permanente HMO Members HMO plans generally require the designation of a primary care provider. You have the right to designate

any primary care provider who participates in the Kaiser Permanente HMO’s network and who is available

to accept you or your family members. Until you make this designation, the HMO plan will designate one for

you. For information on how to select a primary care provider, and for a list of the participating primary care

providers or a list of participating health care professionals who specialize in obstetrics or gynecology,

contact the HMO plan.

For children, you may designate a pediatrician as the primary care provider.

2

You do not need prior authorization from the HMO or from any other person (including a primary care

provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our

network who specializes in obstetrics or gynecology. The health care professional, however, may be

required to comply with certain procedures, including obtaining prior authorization for certain services,

following a pre-approved treatment plan, or procedures for making referrals.

Women’s Health and Cancer Act of 1998 If you or one of your covered dependents has had or is going to have a mastectomy, you may be entitled to

certain benefits under the Women’s Health and Cancer Rights Act (WHCRA). For individuals receiving

mastectomy-related benefits, coverage will be provided for the following services in a manner determined in

consultation with the attending physician and the patient:

All stages of reconstruction of the breast on which the mastectomy was performed

Surgery and reconstruction of the other breast to produce a symmetrical appearance

Prostheses

Treatment of physical complications of all stages of the mastectomy, including lymphedemas.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other

medical and surgical benefits available under your medical plan.

For information on WHCRA benefits or details about any state laws that may apply to your medical plan,

please refer to the benefit plan material for the medical plan in which you are enrolled.

Newborn and Women’s Health Protection Act Federal law protects the benefit rights of mothers and newborns related to any hospital stay in connection

with childbirth. In general, group health plans and health insurance issuers may not:

Restrict benefits for the length of hospital stay for the mother or newborn child to less than 48 hours

following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law

generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the

mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable).

Require that a provider obtain authorization from the plan or the insurance issuer for prescribing a

length of stay of up to 48 hours (or 96 hours).

For details on any state maternity laws that may apply to your medical plan, please refer to the benefits

material for the medical plan in which you are enrolled.

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your

employer, your state may have a premium assistance program that can help pay for coverage, using funds

from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t

be eligible for these premium assistance programs but you may be able to buy individual insurance

coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

3

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a state listed below,

contact your state Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your

dependents might be eligible for either of these programs, contact your state Medicaid or CHIP office or dial

877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a

program that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible

under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t

already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60

days of being determined eligible for premium assistance. If you have questions about enrolling in your

employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer

health plan premiums. The following list of states is current as of July 31, 2015. You should contact

your state for further information on eligibility.

Alabama – Medicaid Website: http://www.myalhipp.com

Phone: 855-692-5447

Alaska – Medicaid Website: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Phone (Outside Anchorage): 888-318-8890

Phone (Anchorage): 907-269-6599

Arizona – CHIP Website: http://www.azahcccs.gov/applicants/categories/KidsCare.aspx

Phone (Outside Maricopa County): 877-764-5437

Phone (Maricopa County): 602-417-5437

Phone (Out-of-State): 800-523-0231

Arkansas — CHIP Website: http://www.arkidsfirst.com/

Phone: 888-474-8275

California – Medi-Cal Website: http://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspx

Phone: 916-874-2215 Sacramento Medi-Cal application line

Email: [email protected]

Colorado – Medicaid Website: http://www.colorado.gov/hcpf

Phone: 800-221-3943

Florida – Medicaid Website: https://www.flmedicaidtplrecovery.com/index.jsp

Phone: 877-357-3268

Georgia – Medicaid Website: http://dch.georgia.gov/ (Click Programs, then Medicaid, then Third Party

Liability, then Health Insurance Premium Payment (HIPP))

Phone: 678-564-1162

Idaho – Medicaid and CHIP Website:

http://healthandwelfare.idaho.gov/FoodCashAssistance/HealthCoverageAssistance/

tabid/2882/Default.aspx

Phone: 877-456-1233

http://www.myalhipp.com/

http://health.hss.state.ak.us/dpa/programs/medicaid

http://www.azahcccs.gov/applicants/categories/KidsCare.aspx

http://www.arkidsfirst.com/

http://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspx

mailto:[email protected]

http://www.colorado.gov/hcpf

https://www.flmedicaidtplrecovery.com/index.jsp

http://dch.georgia.gov/

4

Indiana – Medicaid Website: http://www.in.gov/fssa

Phone: 800-889-9949

Iowa – Medicaid Website: http://www.dhs.state.ia.us/hipp/

Phone: 888-346-9562

Kansas – Medicaid Website: http://www.kdheks.gov/hcf/

Phone: 800-792-4884

Kentucky – Medicaid Website: http://chfs.ky.gov/dms/default.htm

Phone: 800-635-2570

Louisiana – Medicaid Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 888-695-2447

Maine – Medicaid Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 800-977-6740

TTY: 800-977-6741

Massachusetts – Medicaid

and CHIP

Medicaid & CHIP Website: http://www.mass.gov/MassHealth

Medicaid & CHIP Phone: 800-462-1120

Minnesota – Medicaid Website: http://www.dhs.state.mn.us/id_006254 (Click A-Z Topics, then Medical

Assistance)

Phone (Outside Twin City area): 800-657-3739

Phone (Twin City area): 651-431-2670

Missouri – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

Phone: 573-751-2005

Montana – Medicaid Website: http://medicaid.mt.gov/member

Phone: 800-694-3084

Nebraska – Medicaid Website: http://www.ACCESSNebraska.ne.gov

Phone: 855-632-7633

Nevada – Medicaid Website: http://dwss.nv.gov/

Phone: 800-992-0900

New Hampshire – Medicaid Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf

Phone: 603-271-5218

New Jersey – Medicaid and

CHIP

Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/

Medicaid Phone: 609-631-2392

CHIP Website: http://www.njfamilycare.org/index.html

CHIP Phone: 800-701-0710

New Mexico – Medicaid and

CHIP

Medicaid & CHIP Website: http://www.hsd.state.nm.us/mad/index.html


New York – Medicaid Website: http://www.nyhealth.gov/health_care/medicaid/

Phone: 800-541-2831

North Carolina – Medicaid Website: http://www.ncdhhs.gov/dma/medicaid/hipp.htm

Phone: 919-855-4100

North Dakota – Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/

Phone: 800-755-2604

Oklahoma – Medicaid Website: http://www.insureoklahoma.org

Phone: 888-365-3742

http://www.in.gov/fssa

http://www.dhs.state.ia.us/hipp/

http://www.kdheks.gov/hcf/

http://chfs.ky.gov/dms/default.htm

http://www.maine.gov/dhhs/ofi/public-assistance/index.html

http://www.mass.gov/MassHealth

http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

http://www.accessnebraska.ne.gov/

http://dwss.nv.gov/

http://www.state.nj.us/humanservices/dmahs/clients/medicaid/

http://www.njfamilycare.org/index.html

http://www.hsd.state.nm.us/mad/index.html

http://www.nyhealth.gov/health_care/medicaid/

http://www.ncdhhs.gov/dma/medicaid/hipp.htm

http://www.nd.gov/dhs/services/medicalserv/medicaid/

http://www.insureoklahoma.org/

5

Oregon – Medicaid and CHIP Medicaid & CHIP Website: http://www.oregonhealthykids.gov

http://www.hijossaludablesoregon.gov


Pennsylvania – Medicaid Website: http://www.dhs.state.pa.us/hipp

Phone: 800-692-7462

Rhode Island – Medicaid Website: http://www.eohhs.ri.gov/

Phone: 401-462-5300

South Carolina – Medicaid Website: http://www.scdhhs.gov

Phone: 803-264-6838/6847 (HIPP line)

South Dakota – Medicaid Website: http://dss.sd.gov

Phone: 888-828-0059

Texas – Medicaid Website: http://www.gethipptexas.com/

Phone: 800-440-0493

Utah – Medicaid and CHIP Medicaid Website: http://health.utah.gov/medicaid

CHIP Website: http://health.utah.gov/chip


Vermont– Medicaid Website: http://www.greenmountaincare.org

Phone: 800-250-8427

Virginia – Medicaid and

CHIP

Medicaid & CHIP Website:

http://www.coverva.org/programs_premium_assistance.cfm


Washington – Medicaid Website: http://www.hca.wa.gov/medicaid/premiumpymt/Pages/index.aspx

Phone: 800-562-3022, ext. 15473

West Virginia – Medicaid Website: http://www.wvrecovery.com/hipp.asp

Phone: 877-598-5820, HMS Third Party Liability

Wisconsin – Medicaid Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm

Phone: 800-362-3002

Wyoming – Medicaid Website: https://wyequalitycare.acs-inc.com/

Phone: 307-777-7531

To see if any other states have added a premium assistance program since July 31, 2015, or for more

information on special enrollment rights, contact either:

U.S. Department of Labor

Employee Benefits Security Administration

www.dol.gov/ebsa

866-444-EBSA (3272)

U.S. Department of Health and Human Services

Centers for Medicare & Medicaid Services

www.cms.hhs.gov

877-267-2323, Menu Option 4, Ext. 6156

http://www.oregonhealthykids.gov/

http://www.hijossaludablesoregon.gov/

http://www.scdhhs.gov/

http://dss.sd.gov/

http://www.gethipptexas.com/

http://health.utah.gov/chip

http://www.greenmountaincare.org/

http://www.coverva.org/programs_premium_assistance.cfm

http://www.hca.wa.gov/medicaid/premiumpymt/Pages/index.aspx

http://www.wvrecovery.com/hipp.asp

6

Continuation Coverage Rights Under COBRA You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This

notice has important information about your right to COBRA continuation coverage, which is a temporary

extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may

become available to you and your family, and what you need to do to protect your right to get it. When you

become eligible for COBRA, you may also become eligible for other coverage options that may cost less

than COBRA continuation coverage.

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget

Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other

members of your family when group health coverage would otherwise end. For more information about your

rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan

Description or contact the Plan Administrator.

You may have other options available to you when you lose group health coverage. For example, you may

be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage

through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-

pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health

plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late

enrollees.

What Is COBRA Continuation Coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of

a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice.

After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified

beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if

coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who

elect COBRA continuation coverage must pay for COBRA continuation coverage.

If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan

because of the following qualifying events:

Your hours of employment are reduced, or

Your employment ends for any reason other than your gross misconduct.

If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under

the Plan because of the following qualifying events:

Your spouse dies;

Your spouse’s hours of employment are reduced;

Your spouse’s employment ends for any reason other than his or her gross misconduct;

Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or

You become divorced or legally separated from your spouse.

7

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because

of the following qualifying events:

The parent-employee dies;

The parent-employee’s hours of employment are reduced;

The parent-employee’s employment ends for any reason other than his or her gross misconduct;

The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);

The parents become divorced or legally separated; or

The child stops being eligible for coverage under the Plan as a “dependent child.”

When Is COBRA Continuation Coverage Available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator

has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of

the following qualifying events:

The end of employment or reduction of hours of employment;

Death of the employee;

The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).

For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent

child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60

days after the qualifying event occurs. You must provide this notice to the Benefits Department at

[email protected] or by calling 844-282-8283.

How Is COBRA Continuation Coverage Provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation

coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an

independent right to elect COBRA continuation coverage. Covered employees may elect COBRA

continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on

behalf of their children.

COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months

due to employment termination or reduction of hours of work. Certain qualifying events, or a second

qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36

months of coverage.

There are also ways in which this 18-month period of COBRA continuation coverage can be extended:

Disability Extension of 18-month Period of COBRA Continuation Coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and

you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to

an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability

would have to have started at some time before the 60th day of COBRA continuation coverage and must

last at least until the end of the 18-month period of COBRA continuation coverage.

8

Second Qualifying Event Extension of 18-month Period of Continuation Coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage,

the spouse and dependent children in your family can get up to 18 additional months of COBRA

continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second

qualifying event. This extension may be available to the spouse and any dependent children getting

COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare

benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops

being eligible under the Plan as a dependent child. This extension is only available if the second qualifying

event would have caused the spouse or dependent child to lose coverage under the Plan had the first

qualifying event not occurred.

Are There Other Coverage Options Besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you

and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage

options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these

options may cost less than COBRA continuation coverage. You can learn more about many of these

options at www.healthcare.gov.

If You Have Questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the

contact or contacts identified below. For more information about your rights under the Employee Retirement

Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other

laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of

Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa.

(Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s

website.) For more information about the Marketplace, visit www.healthcare.gov.

Keep Your Plan Informed of Address Changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of

family members. You should also keep a copy, for your records, of any notices you send to the Plan

Administrator.

HIPAA Privacy Notice Please carefully review this notice. It describes how medical information about you may be used

and disclosed and how you can get access to this information.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) imposes numerous requirements

on the use and disclosure of individual health information by Lucky Brand health plans. This information,

known as protected health information, includes almost all individually identifiable health information held by

a plan — whether received in writing, in an electronic medium, or as an oral communication. This notice

describes the privacy practices of these plans: Lucky Choice PPO Plan, Lucky Choice HDHP, Lucky Choice

HDHP Saver, California Kaiser Permanente HMO, and Hawaii Kaiser Permanente HMO. The plans covered

9

by this notice may share health information with each other to carry out treatment, payment, or health care

operations. These plans are collectively referred to as the Plan in this notice, unless specified otherwise.

The Plan’s Duties with Respect to Health Information About You The Plan is required by law to maintain the privacy of your health information and to provide you with this

notice of the Plan’s legal duties and privacy practices with respect to your health information. If you

participate in an insured plan option, you will receive a notice directly from the Insurer. It’s important to note

that these rules apply to the Plan, not Lucky Brand as an employer — that’s the way the HIPAA rules work.

Different policies may apply to other Lucky Brand programs or to data unrelated to the Plan.

How the Plan may Use or Disclose Your Health Information The privacy rules generally allow the use and disclosure of your health information without your permission

(known as an authorization) for purposes of health care treatment, payment activities, and health care

operations. Here are some examples of what that might entail:

• Treatment includes providing, coordinating, or managing health care by one or more health care

providers or doctors. Treatment can also include coordination or management of care between a

provider and a third party, and consultation and referrals between providers. For example, the Plan may

share your health information with physicians who are treating you.

• Payment includes activities by this Plan, other plans, or providers to obtain premiums, make coverage

determinations, and provide reimbursement for health care. This can include determining eligibility,

reviewing services for medical necessity or appropriateness, engaging in utilization management

activities, claims management, and billing; as well as performing “behind the scenes” plan functions,

such as risk adjustment, collection, or reinsurance. For example, the Plan may share information about

your coverage or the expenses you have incurred with another health plan to coordinate payment of

benefits.

• Health care operations include activities by this Plan (and, in limited circumstances, by other plans or

providers), such as wellness and risk assessment programs, quality assessment and improvement

activities, customer service, and internal grievance resolution. Health care operations also include

evaluating vendors; engaging in credentialing, training, and accreditation activities; performing

underwriting or premium rating; arranging for medical review and audit activities; and conducting

business planning and development. For example, the Plan may use information about your claims to

audit the third parties that approve payment for Plan benefits.

The amount of health information used, disclosed or requested will be limited and, when needed, restricted

to the minimum necessary to accomplish the intended purposes, as defined under the HIPAA rules. If the

Plan uses or discloses PHI for underwriting purposes, the Plan will not use or disclose PHI that is your

genetic information for such purposes.

How the Plan may Share Your Health Information with Lucky Brand The Plan, or its health insurer or HMO, may disclose your health information without your written

authorization to Lucky Brand for plan administration purposes. Lucky Brand may need your health

information to administer benefits under the Plan. Lucky Brand agrees not to use or disclose your health

information other than as permitted or required by the Plan documents and by law. Members of the Benefits

10

and Payroll departments are the only Lucky Brand employees who will have access to your health

information for plan administration functions.

Here’s how additional information may be shared between the Plan and Lucky Brand, as allowed under the

HIPAA rules:

• The Plan, or its insurer or HMO, may disclose “summary health information” to Lucky Brand, if

requested, for purposes of obtaining premium bids to provide coverage under the Plan or for modifying, amending, or terminating the Plan. Summary health information is information that summarizes participants’ claims information, from which names and other identifying information have been removed.

• The Plan, or its insurer or HMO, may disclose to Lucky Brand information on whether an individual is participating in the Plan or has enrolled or disenrolled in an insurance option or HMO offered by the Plan.

In addition, you should know that Lucky Brand cannot and will not use health information obtained from the

Plan for any employment-related actions. However, health information collected by Lucky Brand from other

sources — for example, under the Family and Medical Leave Act, Americans with Disabilities Act, or

workers’ compensation programs — is not protected under HIPAA (although this type of information may be

protected under other federal or state laws).

Other Allowable Uses or Disclosures of Your Health Information In certain cases, your health information can be disclosed without authorization to a family member, close

friend, or other person you identify who is involved in your care or payment for your care. Information about

your location, general condition, or death may be provided to a similar person (or to a public or private entity

authorized to assist in disaster relief efforts). You’ll generally be given the chance to agree or object to

these disclosures (although exceptions may be made — for example, if you’re not present or if you’re

incapacitated). In addition, your health information may be disclosed without authorization to your legal

representative.

The Plan also is allowed to use or disclose your health information without your written authorization for the

following activities:

Workers’ compensation

Disclosures to workers’ compensation or similar legal programs that provide benefits for work-related injuries or illness without regard to fault, as authorized by and necessary to comply with the laws

Necessary to prevent serious threat to health or safety

Disclosures made in the good-faith belief that releasing your health information is necessary to prevent or lessen a serious and imminent threat to public or personal health or safety, if made to someone reasonably able to prevent or lessen the threat (or to the target of the threat); includes disclosures to help law enforcement officials identify or apprehend an individual who has admitted participation in a violent crime that the Plan reasonably believes may have caused serious physical harm to a victim, or where it appears the individual has escaped from prison or from lawful custody

11

Public health activities

Disclosures authorized by law to persons who may be at risk of contracting or spreading a disease or condition; disclosures to public health authorities to prevent or control disease or report child abuse or neglect; and disclosures to the Food and Drug Administration to collect or report adverse events or product defects

Victims of abuse, neglect, or domestic violence

Disclosures to government authorities, including social services or protected services agencies authorized by law to receive reports of abuse, neglect, or domestic violence, as required by law or if you agree or the Plan believes that disclosure is necessary to prevent serious harm to you or potential victims (you’ll be notified of the Plan’s disclosure if informing you won’t put you at further risk)

Judicial and administrative proceedings

Disclosures in response to a court or administrative order, subpoena, discovery request, or other lawful process (the Plan may be required to notify you of the request or receive satisfactory assurance from the party seeking your health information that efforts were made to notify you or to obtain a qualified protective order concerning the information)

Law enforcement purposes

Disclosures to law enforcement officials required by law or legal process, or to identify a suspect, fugitive, witness, or missing person; disclosures about a crime victim if you agree or if disclosure is necessary for immediate law enforcement activity; disclosures about a death that may have resulted from criminal conduct; and disclosures to provide evidence of criminal conduct on the Plan’s premises

Decedents Disclosures to a coroner or medical examiner to identify the deceased or determine cause of death; and to funeral directors to carry out their duties

Organ, eye, or tissue donation

Disclosures to organ procurement organizations or other entities to facilitate organ, eye, or tissue donation and transplantation after death

Research purposes

Disclosures subject to approval by institutional or private privacy review boards, subject to certain assurances and representations by researchers about the necessity of using your health information and the treatment of the information during a research project

Health oversight activities

Disclosures to health agencies for activities authorized by law (audits, inspections, investigations, or licensing actions) for oversight of the health care system, government benefits programs for which health information is relevant to beneficiary eligibility, and compliance with regulatory programs or civil rights laws

Specialized government functions

Disclosures about individuals who are Armed Forces personnel or foreign military personnel under appropriate military command; disclosures to authorized federal officials for national security or intelligence activities; and disclosures to correctional facilities or custodial law enforcement officials about inmates

HHS investigations Disclosures of your health information to the Department of Health and Human Services to investigate or determine the Plan’s compliance with the HIPAA privacy rule

Except as described in this notice, other uses and disclosures will be made only with your written

authorization. For example, in most cases, the Plan will obtain your authorization before it communicates

with you about products or programs if the Plan is being paid to make those communications. If we keep

psychotherapy notes in our records, we will obtain your authorization in some cases before we release

those records. The Plan will never sell your health information unless you have authorized us to do so. You

may revoke your authorization as allowed under the HIPAA rules. However, you can’t revoke your

12

authorization with respect to disclosures the Plan has already made. You will be notified of any

unauthorized access, use, or disclosure of your unsecured health information as required by law.

The Plan will notify you if it becomes aware that there has been a loss of your health information in a

manner that could compromise the privacy of your health information.

Your Individual Rights You have the following rights with respect to your health information the Plan maintains. These rights are

subject to certain limitations, as discussed below. This section of the notice describes how you may

exercise each individual right. See the table at the end of this notice for information on how to submit

requests.

Right to Request Restrictions on Certain Uses and Disclosures of Your Health Information and the Plan’s Right to Refuse You have the right to ask the Plan to restrict the use and disclosure of your health information for treatment,

payment, or health care operations, except for uses or disclosures required by law. You have the right to

ask the Plan to restrict the use and disclosure of your health information to family members, close friends,

or other persons you identify as being involved in your care or payment for your care. You also have the

right to ask the Plan to restrict use and disclosure of health information to notify those persons of your

location, general condition, or death — or to coordinate those efforts with entities assisting in disaster relief

efforts. If you want to exercise this right, your request to the Plan must be in writing.

The Plan is not required to agree to a requested restriction. If the Plan does agree, a restriction may later be

terminated by your written request, by agreement between you and the Plan (including an oral agreement),

or unilaterally by the Plan for health information created or received after you’re notified that the Plan has

removed the restrictions. The Plan may also disclose health information about you if you need emergency

treatment, even if the Plan has agreed to a restriction.

An entity covered by these HIPAA rules (such as your health care provider) or its business associate must

comply with your request that health information regarding a specific health care item or service not be

disclosed to the Plan for purposes of payment or health care operations if you have paid out of pocket and

in full for the item or service.

Right to Receive Confidential Communications of Your Health Information If you think that disclosure of your health information by the usual means could endanger you in some way,

the Plan will accommodate reasonable requests to receive communications of health information from the

Plan by alternative means or at alternative locations.

If you want to exercise this right, your request to the Plan must be in writing and you must include a

statement that disclosure of all or part of the information could endanger you.

Right to Inspect and Copy your Health Information With certain exceptions, you have the right to inspect or obtain a copy of your health information in a

“designated record set.” This may include medical and billing records maintained for a health care provider;

13

enrollment, payment, claims adjudication, and case or medical management record systems maintained by

a plan; or a group of records the Plan uses to make decisions about individuals. However, you do not have

a right to inspect or obtain copies of psychotherapy notes or information compiled for civil, criminal, or

administrative proceedings. The Plan may deny your right to access, although in certain circumstances, you

may request a review of the denial.

If you want to exercise this right, your request to the Plan must be in writing. Within 30 days of receipt of

your request, the Plan will provide you with one of these responses:

• The access or copies you requested

• A written denial that explains why your request was denied and any rights you may have to have the

denial reviewed or file a complaint

• A written statement that the time period for reviewing your request will be extended for no more than 30

more days, along with the reasons for the delay and the date by which the Plan expects to address your

request

You may also request your health information be sent to another entity or person, so long as that request is

clear, conspicuous and specific. The Plan may provide you with a summary or explanation of the

information instead of access to or copies of your health information, if you agree in advance and pay any

applicable fees. The Plan also may charge reasonable fees for copies or postage. If the Plan doesn’t

maintain the health information but knows where it is maintained, you will be informed where to direct your

request.

If the Plan keeps your records in an electronic format, you may request an electronic copy of your health

information in a form and format readily producible by the Plan. You may also request that such electronic

health information be sent to another entity or person, so long as that request is clear, conspicuous, and

specific. Any charge that is assessed to you for these copies must be reasonable and based on the Plan’s

cost.

Right to Amend Your Health Information That Is Inaccurate or Incomplete With certain exceptions, you have a right to request that the Plan amend your health information in a

designated record set. The Plan may deny your request for a number of reasons. For example, your

request may be denied if the health information is accurate and complete, was not created by the Plan

(unless the person or entity that created the information is no longer available), is not part of the designated

record set, or is not available for inspection (e.g., psychotherapy notes or information compiled for civil,

criminal, or administrative proceedings).

If you want to exercise this right, your request to the Plan must be in writing, and you must include a

statement to support the requested amendment. Within 60 days of receipt of your request, the Plan will take

one of these actions:

• Make the amendment as requested

• Provide a written denial that explains why your request was denied and any rights you may have to

disagree or file a complaint

14

• Provide a written statement that the time period for reviewing your request will be extended for no more

than 30 more days, along with the reasons for the delay and the date by which the Plan expects to

address your request

Right to Receive an Accounting of Disclosures of Your Health Information You have the right to a list of certain disclosures of your health information the Plan has made. This is often

referred to as an “accounting of disclosures.” You generally may receive this accounting if the disclosure is

required by law, in connection with public health activities, or in similar situations listed in the table earlier in

this notice, unless otherwise indicated below.

You may receive information on disclosures of your health information for up to six years before the date of

your request. You do not have a right to receive an accounting of any disclosures made in any of these

circumstances:

• For treatment, payment, or health care operations

• To you about your own health information

• Incidental to other permitted or required disclosures

• Where authorization was provided

• To family members or friends involved in your care (where disclosure is permitted without authorization)

• For national security or intelligence purposes or to correctional institutions or law enforcement officials

in certain circumstances

• As part of a “limited data set” (health information that excludes certain identifying information)

In addition, your right to an accounting of disclosures to a health oversight agency or law enforcement

official may be suspended at the request of the agency or official.

If you want to exercise this right, your request to the Plan must be in writing. Within 60 days of the request,

the Plan will provide you with the list of disclosures or a written statement that the time period for providing

this list will be extended for no more than 30 more days, along with the reasons for the delay and the date

by which the Plan expects to address your request. You may make one request in any 12-month period at

no cost to you, but the Plan may charge a fee for subsequent requests. You’ll be notified of the fee in

advance and have the opportunity to change or revoke your request.

Right to Obtain a Paper Copy of This Notice From the Plan Upon Request You have the right to obtain a paper copy of this privacy notice upon request. Even individuals who agreed

to receive this notice electronically may request a paper copy at any time.

Changes to the Information in This Notice The Plan must abide by the terms of the privacy notice currently in effect. This notice takes effect on

January 1, 2016. However, the Plan reserves the right to change the terms of its privacy policies, as

described in this notice, at any time and to make new provisions effective for all health information that the

Plan maintains. This includes health information that was previously created or received, not just health

information created or received after the policy is changed. If changes are made to the Plan’s privacy

policies described in this notice, you will be provided with a revised privacy notice.

15

Complaints If you believe your privacy rights have been violated or your Plan has not followed its legal obligations under

HIPAA, you may complain to the Plan and to the Secretary of Health and Human Services. You won’t be

retaliated against for filing a complaint. To file a complaint, contact the Benefits Department at

[email protected] or 844-282-8283.

Contact For more information on the Plan’s privacy policies or your rights under HIPAA, contact the Benefits

Department at [email protected] or 844-282-8283.

Important Notice from Lucky Brand About Creditable Prescription Drug Coverage and Medicare

The purpose of this notice is to advise you that the prescription drug coverage listed below under the Lucky

Brand medical plans is expected to pay out, on average, at least as much as the standard Medicare

prescription drug coverage will pay in 2016. This is known as “creditable coverage.”

Why this is important. If you or your covered dependent(s) are enrolled in any prescription drug coverage

during 2016 listed in this notice and are or become covered by Medicare, you may decide to enroll in a

Medicare prescription drug plan later and not be subject to a late enrollment penalty — as long as you had

creditable coverage within 63 days of your Medicare prescription drug plan enrollment. You should keep

this notice with your important records.

If you or your family members aren’t currently covered by Medicare and won’t become covered by Medicare

in the next 12 months, this notice doesn’t apply to you.

Notice of Creditable Coverage Please read this notice carefully. It has information about prescription drug coverage with Lucky Brand and

prescription drug coverage available for people with Medicare. It also tells you where to find more

information to help you make decisions about your prescription drug coverage.

You may have heard about Medicare’s prescription drug coverage (called Part D), and wondered how it

would affect you. Prescription drug coverage is available to everyone with Medicare through Medicare

prescription drug plans. All Medicare prescription drug plans provide at least a standard level of coverage

set by Medicare. Some plans also offer more coverage for a higher monthly premium.

Individuals can enroll in a Medicare prescription drug plan when they first become eligible, and each year

from October 15 through December 7. Individuals leaving employer/union coverage may be eligible for a

Medicare Special Enrollment Period.

If you are covered by one of the Lucky Brand prescription drug plans listed below, you’ll be interested to

know that coverage is, on average, at least as good as standard Medicare prescription drug coverage for

16

2016. This is called creditable coverage. Coverage under one of these plans will help you avoid a late Part

D enrollment penalty if you are or become eligible for Medicare and later decide to enroll in a Medicare

prescription drug plan.

UHC Lucky Choice HDHP

UHC Lucky Choice HDHP Saver

UHC Lucky Choice PPO

Kaiser Permanente HMO plans (available to some employees in California and in Hawaii)

If you decide to enroll in a Medicare prescription drug plan and you are an active employee or family

member of an active employee, you may also continue your employer coverage. In this case, the employer

plan will continue to pay primary or secondary as it had before you enrolled in a Medicare prescription drug

plan. If you waive or drop Lucky Brand coverage, Medicare will be your only payer. You can re-enroll in the

employer plan in January 2016 or if you have a special enrollment event for the Lucky Brand plan.

You should know that if you waive or leave coverage with Lucky Brand and you go 63 days or longer

without creditable prescription drug coverage (once your applicable Medicare enrollment period ends), your

monthly Part D premium will go up at least 1% per month for every month that you did not have creditable

coverage. For example, if you go 19 months without coverage, your Medicare prescription drug plan

premium will always be at least 19% higher than what most other people pay. You’ll have to pay this higher

premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until

the following October to enroll in Part D.

You may receive this notice at other times in the future – such as before the next period you can enroll in

Medicare prescription drug coverage, if this Lucky Brand coverage changes, or upon your request.

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. Medicare participants will get a copy of the handbook in the mail every year from Medicare.

You may also be contacted directly by Medicare prescription drug plans. Here’s how to get more

information about Medicare prescription drug plans:

Visit www.medicare.gov for personalized help.

Call your State Health Insurance Assistance Program (see a copy of the Medicare & You handbook

for the telephone number).

Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is

available. Information about this extra help is available from the Social Security Administration (SSA). For

more information about this extra help, visit SSA online at www.socialsecurity.gov or call 1-800-772-1213

(TTY 1-800-325-0778).

17

Remember: Keep this notice. If you enroll in a Medicare prescription drug plan after your applicable

Medicare enrollment period ends, you may need to provide a copy of this notice when you join a Part D plan

to show that you are not required to pay a higher Part D premium amount.

For more information about this notice or your prescription drug coverage, contact:

Lucky Brand Benefits Department

540 S. Santa Fe Ave

Los Angeles, CA 90043

844-282-8283

October 1, 2015

18

New Health Insurance Marketplace Coverage

Options and Your Health Coverage

PART A: General Information “Health care reform” refers to the Affordable Care Act (ACA), which was passed in 2010. The law is

intended to extend access to medical coverage to nearly everyone in the U.S., eliminate restrictions on key

benefits, and help control the country’s rising health costs. As of January 1, 2014, the ACA requires almost

everyone in the U.S. to have health insurance or pay a penalty. This is called the individual mandate.

To help satisfy this requirement, there is a new way to buy health insurance: the health insurance

marketplace. To assist you as you evaluate options for you and your

family, this notice provides some basic information about the

Marketplace.

What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets

your needs and fits your budget. The Marketplace offers "one-stop

shopping" to find and compare private health insurance options. You may

also be eligible for a new kind of tax credit that lowers your monthly

premium right away. Open enrollment for health insurance coverage

through the Marketplace begins in November 2015 for coverage starting

as early as January 1, 2016.

Can I Save Money on my Health Insurance Premiums in the Marketplace? No. Because you are eligible for a Lucky Brand medical plan, you will pay

the full cost of health coverage insurance purchased through the

marketplace. To qualify for a subsidy from the government to help pay for

coverage through the marketplace, you must meet both of the following

requirements:

• You don’t already have access to a plan that meets the ACA’s benefit

requirements, and

• You earn below a certain level of income.

Does Lucky Brand Health Coverage Affect My Eligibility for Premium Savings through the Marketplace? Yes. Because you are eligible for medical coverage through Lucky Brand,

you will not be eligible for a tax credit through the marketplace and

may wish to enroll in a Lucky Brand health plan.

Note: If you purchase a health plan through the marketplace instead of

accepting health coverage offered by Lucky Brand, then you may lose the

employer contribution (if any) to the employer-offered coverage. Also, this

A Summary of What You Need to Know: • As of 2014, you must have medical

coverage, or you’ll pay a penalty.

This is called the individual

mandate.

• In 2016, Lucky Brand will offer

medical coverage to:

– Full-time employees working 30

hours or more

– Full-time employees who live in

Hawaii and are working 20 hours

or more

• Lucky Brand also offers medical

coverage to your eligible dependents.

• In addition to Lucky Brand, you can

get medical coverage through many

sources, including through your

spouse’s/partner’s company plan,

private insurance, Medicare (if

eligible), or the new public health

care marketplaces.

• As a Lucky Brand employee, your

best option to meet the individual

mandate will likely be Lucky Brand

plans. The plans available through

the marketplaces are expected to be

more expensive. (However, your

spouse/partner may find that

coverage through his/her employer is

his/her best option.)

19

employer contribution — as well as your employee contribution to employer-offered coverage — is often

excluded from income for Federal and State income tax purposes. Your payments for coverage through the

Marketplace are made on an after-tax basis.

How Can I Get More Information? For more information about your coverage offered by your employer, please check your Summary Plan

Description or contact the Benefits Department at [email protected] or 844-282-8283.

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage

through the Marketplace and its cost. Please visit www.healthcare.gov for more information, including an

online application for health insurance coverage and contact information for a health insurance marketplace

in your area.

PART B: Information About Health Coverage Offered by Lucky Brand This section contains information about any health coverage offered by Lucky Brand. If you decide to

complete an application for coverage in the marketplace, you will be asked to provide this information. This

information is numbered to correspond to the marketplace application.

3. Employer name

Lucky Brand Dungarees, LLC

4. Employer Identification Number (EIN)

95-4363823

5. Employer address

540 S. Santa Fe Ave

6. Employer phone number

844-282-8283

7. City

Los Angeles

8. State

CA

9. ZIP code

90043

10. Who can we contact about employee health coverage at this job?

Lucky Brand Benefits Department

11. Phone number (if different from

above)

12. Email address

[email protected]

The coverage offered by Lucky Brand meets the minimum value standard, and your cost for this coverage

is intended to be affordable, based on employee wages.

If you decide to shop for coverage in the Marketplace, www.healthcare.gov will guide you through the process.

* An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed

benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal

Revenue Code of 1986).

http://www.healthcare.gov/

http://www.healthcare.gov/

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