Medical Plan Details:

Plan Name	BasicAdvantage Plan
Doctor Visit Benefits	$50/day \| 10 per year
Ambulance Benefits	$100/day \| 1 per year
Outpatient Benefits	$100/day \| 1 per year
Emergency Due to Accidental Injury	$500/day \| 1 per year
Urgent Care Benefits	$100/day \| 2 per year
Surgery Benefit	$100/day \| 1 per year
Prescription Drug Benefits	Generic: $25/day \| 8/year Brand Name: Discount Only

Plan Name	Essential Care Plan
Deductible	$0
Copays	$0 / $50 copay for brand name contraceptives
Benefit % Payable by Plan	100% for covered expenses
Preventive Care	Included
Plan Annual Maximum	Unlimited
Plan Lifetime Maximum	Unlimited

Summary of Benefits and Coverage

RSLI Medical Plan →

Summary Plan Description (SPD)

RSLI BasicCare Program SPD →

Benefit Summary

RSLI BasicCare Program →

with

800-351-7500

Affordable Care Act

The ACA requires all businesses with 100 or more full-time equivalent employees (FTEs) to offer health insurance to their full-time workers (working 130 hours of service in a calendar month) or pay a penalty. In addition, the Company must continue to provide access to quality health insurance at an affordable cost.

After Taxes

Included in your W-2 income or subject to income taxes.

Before Taxes

Not included in your W-2 income or subject to income taxes.

Beneficiary

A person or persons you name – using a form accepted by the plan administrator or insurance carrier – to receive benefits in the event of your death.

Brand-Name Drug

A drug that is patented by the FDA and subject to an exclusivity agreement that allows the company to be the sole manufacturer of the drug for a certain number of years.

Coinsurance

The percentage that you pay of a covered service.

Copay

A fixed dollar amount that you pay for a covered service at the time the service is provided.

Covered Service

The health care services that a plan will cover in part or in full based on plan documents.

Deductible

The amount you pay for covered services in a plan year before the plan begins to pay benefits.

Eligibility Date

The day on which you’re eligible to participate in a Your Benefits plan.

Eligible Expense

Expenses incurred for a covered service.

Evidence of Insurability

A statement of proof of a person’s physical condition, occupation, or other factor affecting his or her acceptance for insurance coverage.

Formulary Drug

A drug that’s considered a “preferred choice” based on its effectiveness and cost.

Generic Drug

A prescription drug that has the same active ingredients as a brand-name drug and is subject to the same FDA standards for quality, strength, and purity as its brand-name counterpart, but typically costs less. Not all brandname drugs have generic equivalents.

Late Enrollee

A Jack in the Box or Qdoba employee or eligible dependent who didn’t enroll in the benefit plan when first eligible to join.

Network Provider

Any licensed doctor, hospital, lab, or other health care provider that has contracted to provide members with comprehensive services at discounted rates.

Non-Formulary Drug

A brand-name drug that isn’t on a plan’s formulary list.

Non-Preferred Drug

A brand-name drug that isn’t on a plan’s preferred list.

Out-of-Pocket Maximum

The maximum amount you pay each plan year for covered services. Once you reach your out-of-pocket maximum, the plan pays 100% for additional covered services.

Out-of-network Provider

Any licensed doctor, hospital, lab, or other health care provider that is not part of a provider network.

Plan Year

October 1 through September 30.

Preferred Drug

A drug that’s considered a “preferred choice” based on its effectiveness and cost.

Primary Care Physician

A doctor within an HMO network whom you’ve selected to coordinate your medical care.

Qualifying Life Event

A life event that may allow you to make certain changes to your health plan coverage. This includes marriage, registration of a domestic partnership, legal separation, or divorce; birth, adoption, legal guardianship, or change in custody for a dependent child (or children); the ineligibility or death of a dependent; a move to an area where your current plan isn’t offered; a change in your or your spouse’s employment; or a significant change in health coverage.

Reasonable & Customary Charges

The maximum amount the plan will pay for a service, based on what providers in that geographic area charge for similar services or supplies.

In-Network Benefits	HDHP $1750	HDHP $3500	EPO $800 This plan is now In-Network Only
Retail Prescription (30-day supply) Deductible Generic Preferred Brand Non-preferred Brand Specialty	Pharmacy Deductible is combined with Medical $15 copay after deductible $45 copay after deductible $75 copay after deductible $150 copay after deductible	Pharmacy Deductible is combined with Medical $10 copay after deductible $40 copay after deductible $70 copay after deductible $150 copay after deductible	Pharmacy Deductible is combined with Medical $10 copay $40 copay $70 copay $150 copay
Mail Order Prescription (90-day supply) Deductible Generic Formulary/Brand Brand Non-preferred	Pharmacy Deductible is combined with Medical $30 copay after deductible $90 copay after deductible $150 copay after deductible $150 copay after deductible	Pharmacy Deductible is combined with Medical $20 copay after deductible $80 copay after deductible $140 copay after deductible $150 copay after deductible	Pharmacy Deductible is combined with Medical $20 copay $80 copay $140 copay $150 copay

Documents coming soon!

MedImpact

In-Network Benefits	Cigna Dental HMO	Cigna Dental High PPO
Annual Deductible	$0	$50 / $150
Calendar Year Maximum	N/A	$500
Free Preventive Cleanings	2 per year	2 per year
Basic Services	$5 copay then 0% coinsurance	75% after deductible
Major Services	$5 copay then 0% coinsurance	Not covered
Orthodontic Services	$5 copay then 50% coinsurance	Not covered
Orthodontia Lifetime Max	N/A	$500

Find a Dentist

Is your provider In-Network?

Summary of Benefits

DPPO Limited Plan →
DHMO Plan Summary

Summary Plan Description (SPD)

DPPO Limited SPD →
DPPO Limited SPD LA and MS →
DPPO Limited SPD TX →
DHMO SPD →

Brochures

DHMO Product Brochure (English) →
DHMO Product Brochure (Spanish) →
DPPO FAQ (English) →
DPPO FAQ (Spanish) →
DPPO Network Brochure (English) →
DPPO Network Brochure (Spanish) →

Program Information

Make the Most of your Dental Plan →
Oral Health Integration Plan →
WellnessPlus - Preventive Care That Pays →

with

800-244-6224

In-Network Benefits	Cigna Vision
Exam Copay	$10 exam
Materials Copay	$20
Glasses Allowances	Single: Covered in full Bifocal: Covered in full Trifocal: Covered in full Lenticular: Covered in full
Contacts	Elective: Up to $130 Therapeutic: Covered in full
Frame Retail Allowance	Up to $130 every 12 months

Program Flyers

Plan Coverage Flyer (English)
Plan Coverage Flyer (Spanish)

Summary Plan Description (SPD)

Vision SPD

Summary of Benefits

Summary of Benefits (English)
Summary of Benefits (Spanish)

with

800-244-6224

Health Savings Account

HSAs are savings accounts funded by pre-tax contributions from your paycheck. These accounts earn interest tax free and can be used to help pay for a wide range of medical, prescription, dental and vision expenses.

The money in this account is yours and rolls over from year to year. You can save it or use it for qualified expenses now or anytime in the future. It’s also portable, so if you retire or leave FIVE BELOW, you can take it with you.

Product Highlights

✓ Contributions are pre-tax and are automatically deducted

✓ Funds rollover from year-to-year and are yours to keep

✓ Catch-up contributions are for those aged 55 and older

Documents coming soon!

PayFlex

Flexible Spending Account

An FSA saves you money by reducing your income taxes. You must choose how much to contribute each year, up to the stated limit. Your FSA contributions are automatically deducted from your pay BEFORE any taxes are calculated, and are not reported as income to the IRS. The FSA plan is effective January 1 to December 31 (calendar year).

Existing employees may enroll during Open Enrollment. New Hires must fulfill their eligibility requirements prior to enrolling.

Product Highlights

✓ Contributions are pre-tax and are automatically deducted

✓ Funds do not rollover from year-to-year

Documents coming soon!

PayFlex

Supplemental Life Insurance

If you want additional protection for you and your family, you have the option to buy Supplemental Life Insurance as shown below. Note that you must elect Supplemental Life Insurance for yourself in order to purchase coverage for your dependents.

Product Highlights

✓ Employee Life:Increments of $10,000 from $10,000 up to $500,000

✓ Spouse Life: Increments of $5,000 from $5,000 up to $100,000

✓ Child(ren) Life: $1,000, $2,000, $4,000, $5,000 or $10,000 coverage amounts available

✓ Guarantee Issue $150,000, Spouse - $25,000, Child – N/A (EOI not required)

Company-Paid Benefits

MetLife

ID Watchdog

Your identity is important — it’s what makes you, you. You’ve spent a lifetime building your name and financial reputation. Let us help you better protect it. And, we’ll even go one step further and help you better protect the identities of your family.

Credit Lock

With online and in-app feature, lock your Equifax® credit report2 — and your child’s Equifax credit report — to help provide additional protection against unauthorized access to your credit.

More for Families:

The family plan helps you better protect your loved ones, with each adult getting their own account with all plan features. And, we offer more features that help protect minors than any other provider.

Dedicated Resolution Specialists:

If you become a victim, you don’t have to face it alone. One of our certified resolution specialists will fully manage the case for you until your identity is restored.

Total Pet Program

Five Below is offering you access to one of the nation's best pet benefits plans. Total Pet Program gives you access to the following:

You get:

✓ PetAssure

✓ PetPlus

✓ PetTag

✓ WhiskerDocs

✓ BarkBox

✓ Rover

MetLaw Legal

Life is filled with situations where you might need legal help. From exciting moments like buying a home, to less exciting ones like getting a speeding ticket, we make legal help for life’s big moments affordable, accessible, and easy.

Product Highlights

✓ Access to a network of attorneys whenever you need it.

✓ Get assistance with things like marriage licenses, identity theft, caring for aging parents, and more!

Group Term Life

Get up to $100,000 of guaranteed financial protection in the event of your death to help cover costs such as funeral and daily expenses. You may elect coverage for your spouse and/or child(ren) as well.

Product Highlights

✓ Waiver of premium benefit if laid off from work.

✓ Offers spouse and dependent benefits.

✓ Ability to continue policy if you change employers or retire.

✓ Renews after initial term without requiring medical history.

Accident

Provides cash payments in the event of an accident.

Product Highlights

✓ Pays benefits directly to you.

✓ Family options available.

✓ Payroll-deducted premiums.

Hospital Indemnity

Provides a cash payment of $100 (once per calendar year) if you are hospitalized, and $100 per day for a maximum of 30 days per hospital stay.

Product Highlights

✓ No lifetime maximum.

✓ No waiting period.

✓ Benefits paid directly to the insured.

Critical Illness

Critical illness pays a tax-free lump sum if you’re diagnosed with a covered critical illness. Choose a benefit amount up to $30,000. A cash benefit is payable to you at time of diagnosis of a covered critical illness and is paid regardless of any other coverage.

Product Highlights

✓ No lifetime maximum.

✓ No waiting period.

✓ Benefits paid directly to you.

401(k) Enrollment & Beneficiary Info

Be Sure to Designate a Beneficiary: You can set up your beneficiary information by going to www.401k.com or by calling a Principal Representative at 800-547-7754. Simply request a Designation of Beneficiary Form to fill out and return to Principal.

Enrollment Platform

Employee Stock Purchase Plan (ESPP)

We offer the chance to build your investment portfolio by purchasing Five Below stock at a discounted rate.

Eligibility:

You are eligible to purchase company stock during the first offering period after six months of employment. Offerings happen twice a year in January and July.

Enrollment:

You may enroll at any point after becoming eligible.

Shopping & Travel Discount from PerkSpot

As a Five Below employee you receive perks and discounts on more than 900 local and national merchants like Apple, Samsung, Sprint, Six Flags, and Disney.

Whether it’s greater discount percentages or benefits like free shipping, this exlusive benefit can help you get more for your money! Plus, PerkSpot includes a newly released

Travel Feature with exclusive discounts up to 60% on hotels in hundreds of destinations worldwide.

Cigna's Healthy Pregancy, Healthy Babies Program

Enrolling in this program is an important first step toward a healthy future for you and your baby. All Cigna Healthy Pregnancies, Healthy Babies services are confidential, and your private information will not be shared with Five Below.

Plan for a Healthy Pregnancy:

When you enroll before becoming pregnant, we can help you be as healthy as possible. You’ll have access to preconception planning tools and resources, including information from the March of Dimes on eating right, maintaining a healthy weight, taking prenatal vitamins, stopping alcohol and tobacco use, and controlling any medical conditions you may have.

Support During Your Pregnancy:

Tell Cigna about your pregnancy so they can meet your needs. You can ask them anything – your coach, who has a nursing background, is there to support you during your whole pregnancy. You’ll even get a pregnancy journal with information, charts, and tools to help you have a happy nine months.

Start Now:

Cigna can help you stay healthy before and during your pregnancy and in the days and weeks following your baby’s birth. Call 800-615-2906 to enroll today. Download the new app by searching for “Cigna Healthy Pregnancies” in the App Store to get support through your entire pregnancy with tips and tools.

Ovia

Manage your parenthood journey with Ovia Health! From preconception to returning to work and navigating life as a new parent, Ovia offers three apps to guide you on your journey.

Fertility:

Track your period, symptoms, moods and more! Receive accurate predictions for period and ovulation, connect with an anonymous community of women and read personalized summaries of your health and fertility.

Pregnancy:

Follow your baby's growth by tracking pregnancy, symptoms moods and more. Connect with other moms-to-be for support, check food and medication with safety lookups, and more.

Parenting:

Celebrate memories and milestones by inviting friends and family to follow along, upload photos and videos of precious moments, and track your child's growth and development.

Download apps now

Employee Assistance Program

Our FREE and confidential Employee Assistance Program (EAP) helps you find balance between work and home life. Your EAP benefits cover five sessions of counseling at no cost to you. If you are interested in counseling, you have three choices available: face-to-face counseling, secure video counseling, or scheduled telephone counseling sessions which are available early morning, late in the evening, and on weekends. If you choose to continue to see the counselor beyond the initial sessions, you may be able to use your health insurance benefits for more long-term coverage.

Five Below offers this program to you and your immediate family (spouse or domestic partner, dependent children up to age 26) at no cost to you.

Directions on how to contact the Employee Assistance Program:

If you need help or guidance, call a counselor at 800-437-0911 or email clientservice@carebridge.com or visit www.myliferesource.com

Useful Forms:

✓ One-Page Flyer

✓ Counseling Services

✓ Tobacco Cessation

✓ Personal Life Coaching

✓ Stress Management

LifeWorks Employee Assistance Program

Get immediate access to specialized professionals in counseling, social work, human services and psychology. You have access to the LifeWorks network of thousands of master’s level counselors and affiliates.

Benefit Features

✓ Get support with financial and legal issues

✓ Receive 5 free appointments included in your Niagara benefits

✓ Enjoy hassle-free scheduling with LifeWork's easy-to-use app

Get started

Employee Assistance Program

Flyer

LifeWorks

Compliance Notices

Compliance Document (English) →
Compliance Document (Spanish) →

Privacy

Website Privacy Statement →

Summary of Benefits and Coverage

RSLI Medical Plan →

Benefit Summary

RSLI BasicCare Program →

Medicare Part D Notice

Non-Creditable Coverage →

Plan Document

Wrap Plan Document (English) →
Wrap Plan Document (Spanish) →

Wrap Summary Plan Document

Summary Plan Document (English) →
Summary Plan Document (Spanish) →

Your Benefits

BENEFITS HUB

Medical Plans

BasicAdvantage Plan

Essential Care Plan

Dental Plans

Dental HMO

Dental PPO

Vision Plan

Cigna Vision

Supplemental Benefits

Included Benefits:

Wellness

Compliance