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2021 BENEFITS GUIDEBetter Choices. Better Life.Your enrollment is time sensitive.See inside for details.For Weekly-Paid Employees
Welcome to YourDollar General Benefits!Better Choices. Better Life.You’ll find everything you need in thisBenefits Guide to learn, choose and enroll.Review the Legal Notice posted onDGme for important plan information.See what’s insideEnrollment Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Eligibility and Mid-Year Changes. . . . . . . . . . . . . . . . . . 4Better Life Wellness Program . . . . . . . . . . . . . . . . . . . . 62021 Medical Plan Options. . . . . . . . . . . . . . . . . . . . . . 82021 Medical and Prescription (weekly rates). . . . . . . . 10Save Time and Money on Medical Care. . . . . . . . . . . . . 11Prescription Drug. . . . . . . . . . . . . . . . . . . . . . . . . . .12Save Time and Money on Prescription Drugs . . . . . . . . .14Additional Benefits to Protect Your Family. . . . . . . . . . . . 15Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Flexible Spending Accounts (FSAs) . . . . . . . . . . . . . . . . .18Term Life and AD&D Insurance. . . . . . . . . . . . . . . . . . . 19Disability Coverage. . . . . . . . . . . . . . . . . . . . . . . . . 20401(k) Savings and Retirement . . . . . . . . . . . . . . . . . . .21Employee Assistance Program (EAP). . . . . . . . . . . . . . . 22Contacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
EnrollmentBasicsTo enroll in, change or cancel your coverage,log on to DGme and click “DGWell — Benefitsand Wellness Platform” on the home page.DGWell, Your Benefits andWellness Engagement PlatformAccess information about your benefitprograms, the Enrollment System and otherresources. Plus, participate in digital andtelephonic programs designed to help youfocus on your total well-being — physical,emotional and financial — all in a private,secure environment.To access DGWellthrough DGme: Log on to DGme. Under the Benefits Pillar, click “View”next to “DGWell — Benefits andWellness Platform.” Select “Register Now” and follow theprompts to create a DGWell account. Choose the “Benefits Enrollment System”link to access your enrollment.From the Benefits Enrollment Systemhome page you can:LearnAccess online tools and information to helpyou learn about your benefit options andthe Better Life Wellness Program.ChooseNeed help deciding which Health Planmeets your health care needs? Pilot, ourplan selection tool within the EnrollmentSystem, can help you select the Health Planthat’s right for you.EnrollEnroll within 45 days of your hire datein the Benefits Enrollment System or theEmpyreanGo mobile app: Confirm your elections and dependentcoverage.To access DGWell throughthe CaféWell app: Go to your App Store and search forCaféWell, then download the app. Open the app and select “Register now.” On the next page, enter the sponsor code(DGWell), then click “Submit.” Follow the system prompts to createan account. Choose the “Benefits Enrollment System”link to access your enrollment.If covering your spouse on your Health Plan: Verify your spouse’s access to otheremployer-sponsored health insurance.Indicate whether your spouse is willing tocomplete their own Health Assessment.You’ll find additional details on page 6.Important: You must verify eligibility foreach dependent at the time of enrollment.See page 4 for more details. Upon completing your enrollment,complete your Health Assessment onDGWell to be eligible to earn the BetterLife Wellness and Tobacco-Free Incentives(Health Plan enrollees only).3
Eligibility andMid-Year ChangesEmployeesEligible DependentsYou’re eligible for the full-time Dollar GeneralBenefits Plan if you work in a: Legally married spouse Designated full-time position subject toa 60-day or 90-day waiting period Designated position subject to immediateeligibility as of date of hire Part-time position but averaged 30 hoursor more per week during the initial orstandard measurement periodYou have 45 days from your date of hire, oreligibility date if a part-time employee, to enroll.Your selected benefit will become effective onthe applicable benefits eligibility date, as notedin the enrollment platform.If you have questions regarding your eligibilityor deadline to enroll, call the Benefits ServiceCenter at 1-855-ASK-DGHR (1-855-275-3447). Children under the age of 26*If you are covering a dependent, you will berequired to provide proof of dependent eligibility.For example: If you are covering your spouse — you mustprovide a marriage certificate with recentproof of joint ownership or a copy of yourlatest tax filing. If you are covering a child — you mustprovide a copy of their birth certificate,adoption paperwork, legal guardianshipnotification or a copy of your latest tax filing.Failure to provide the requested documentationby the deadline will result in the dependent(s)not being covered under the plan for the 2021plan year.* Your biological child, stepchild or a child of whom you have legal custody is eligible. Your child will remain eligible for the Plan if thechild becomes disabled while younger than age 26 and covered under the Plan. You must notify the Benefits Service Center at1-855-ASK-DGHR (1-855-275-3447) in a timely manner. Documentation is required.!ImportantBe sure yourdependents’information —such as date ofbirth and SocialSecurity number(SSN) — is correctin the enrollmentsystem.This informationis required to bereported to the IRSaccording to theAffordable Care Act.4
Who’s not eligible Grandchildren A child not primarily dependentupon you or related to you by bloodMid-Year ChangesOther than your initial enrollment and theannual enrollment period held each fall,plan changes can only be made due to aqualifying event, such as birth, adoption,marriage, divorce or if you or your dependentgains or loses other coverage. You will have 45 days from the qualifyingevent date to make the change andprovide the necessary documentation(60 days for birth, adoption, or placementfor adoption). In a timely manner, you must log in2021to the Enrollment System and completethe change to your coverage orcontact the Benefits Service Center at1-855-ASK-DGHR (1-855-275-3447),Option 2, then Option 9, Monday throughFriday, 8 a.m. to 5 p.m. Central time.!Don’t missout onimportantbenefitsupdatesKeep your physicaladdress up-to-dateunder “Update YourPersonal Information”on DGme.In the Enrollment System,add your phone numberand preferred emailaddress to receiveinformation about yourbenefit programs.5
Better LifeWellness ProgramThe Better Life Wellness Program offers ways for you to lead a healthy lifestyle and save onmedical premiums and expenses.1 You can earn up to 480/year in Tobacco-Free PremiumCredits, plus lower out-of-pocket medical and prescription costs.Qualify for Your 2021 Wellness PlanBy completing the Health Assessment onthe DGWell platform by your enrollmentdeadline, you’ll qualify to receive theseWellness Plan incentives:How to Completethe Health Assessment Lower copays for in-network primary careYou and your spouse (if applicable) cancomplete a Health Assessment byfollowing these easy steps: Free generic or 50% off brand-name1. Employees: Log on to DGme.Under the Benefits Pillar, click“DGWell — Benefits and WellnessPlatform.”and urgent care visits — even before you’vemet your annual deductible.eligible maintenance medications. Seepage 14 for details. Waived pharmacy deductible for eligiblemaintenance medications.2You and Your Spouse:Get Healthy Together!The Better Life Wellness Program also givesspouses on the Dollar General Health Planaccess to the same great tools! Whileparticipation is voluntary, we hope all coveredspouses complete a Health Assessment (HA)to better understand their own health risks.If covering a spouse, indicate in theEnrollment System whether your spouse iswilling to complete a Health Assessment (HA)and provide your spouse’s preferred emailaddress. Additional details and instructionsto access the DGWell platform will be emailedto your spouse at the provided email address.If your spouse completes the HA within 31 daysfrom your enrollment deadline, you will avoidpaying the monthly 50 “Spouse WellnessPremium” as of the first payroll following that31-day window.12Spouses: Visit dgwell.cafewell.comor download the CaféWell app (useDGWell as the sponsor code).2. Select “Register Now” and followthe prompts to create your DGWellaccount (if you haven’t already).3. Once logged in, locate the “CompleteYour Health Assessment” card under“Active Programs,” click “Your HealthAssessment,” then “Go Now” to beginyour assessment.Confidentiality & SpouseParticipationTo protect all participants’ confidentiality, youand your spouse will have a separate Better Lifeaccount and login credentials. Your personalhealth information will not be shared with yourspouse, or with Dollar General, in compliancewith HIPAA privacy laws.If it is unreasonably difficult due to a health factor for you to meet the requirements under this program, or if it is medically inadvisablefor you to attempt the requirements of this program, please call 1-800-521-9919, and select Option 3 and then Option 1 to discussyour situation.Refer to page 14 for more information.6
Earn a Tobacco-Free1 Premium CreditIndicate your tobacco-use status on your HA: Are you tobacco-free? Receive a monthly 40 Tobacco-FreePremium Credit. Need help quitting or preventing relapse? The Better Life TobaccoCessation Program can support you in your tobacco-free journey. Plus, if youcomplete2 the program, you’ll earn up to a 480 Tobacco-Free Premium Creditat year-end.3To enroll, upon completing the HA and tobacco-use attestation, join the“My Personal Tobacco Wellness Coach” activity on DGWell and schedule yourfirst call with a coach.123Tobacco products include cigarettes, pipes, cigars, and smokeless forms including chewing tobacco, snuff and dip, andelectronic cigarettes.Program completion is defined as completing four (4) tobacco cessation calls with your coach (once every 45 daysbeginning the day you join the program).If eligible, the year-end credit will be provided as a lump-sum payment on your paycheck. You must be actively enrolledin the Medical Plan at the time of payment to receive the credit. Amount based on number of months in the Medical Planduring the year and subject to applicable tax withholdings.Did You Know? An average trip to the ER fornon-emergency services is 550 while Telehealth will notcost you anything. (See page 11.) On average Expert MedicalOpinion (see page 11) modifies79% of treatment plans forparticipants, in partnership withthe participant’s doctor. Rx Savings Solutions (seepage 14) participants save anaverage of 300 per year ontheir prescriptions.7
2021 MedicalPlan OptionsThink about your health and your budget, then decide if you’d ratherpay less each paycheck for coverage or less at the time you need care.BCBST Medical Coverage, BlueCross BlueShield BlueCard PPOHigh orkIn-NetworkOut-ofNetworkAnnual Deductible1,2Single 7,150 13,300 1,200 2,400 700 1,400 450 800Family 13,300 26,600 2,400 4,800 1,400 2,800 800 1,600Out-of-Pocket MaximumSingle 7,150 13,300 7,150 14,300 7,150 14,300 2,875 5,750Family 13,300 26,600 14,300 28,600 14,300 28,600 5,750 11,500You pay40%;Plan pays60%You pay20%;Plan pays80%You pay40%;Plan pays60%Includes deductibles, coinsurance and copays, if applicableCoinsurance after DeductiblePlan pays100%Plan pays100%You pay30%;Plan pays70%You pay50%;Plan pays50%You pay20%;Plan pays80%Preventive Care3Mammogram, pap smear, prostate screening, colonoscopy, sigmoidoscopy and well-baby immunizations (nodeductible, in-network only)Plan pays100%NotcoveredPlan pays100%NotcoveredPlan pays100%NotcoveredPlan pays100%NotcoveredWellcare ServicesAge six and up, includes regular physicals, blood pressure and periodic cholesterol screening, and flu shotPlan pays100%NotcoveredPlan pays100%NotcoveredPlan pays100%NotcoveredPlan pays100%NotcoveredTelemedicine Teladoc 0 copayPrimary Care Office Visit 0 copay 0 copay 0 copay4Medically necessary (family/general practice, internal medicine, pediatrics, OB/GYN, nurse practitioner)WithWellnessIncentive 40 copayYou pay100% untildeductibleis met 40 copayYou pay50%;Plan pays50% afterdeductible 35 copayYou pay40%;Plan pays60% afterdeductible 30 copayYou pay40%;Plan pays60% afterdeductibleWithoutWellnessIncentiveYou pay100% untildeductibleis metYou pay100% untildeductibleis met 70 copayYou pay50%; Planpays 50%afterdeductible 65 copayYou pay40%; Planpays 60%afterdeductible 60 copayYou pay40%; Planpays 60%afterdeductible8
BCBST Medical Coverage, BlueCross BlueShield BlueCard PPOHigh um2In-NetworkOut-ofNetworkSpecialist Office VisitWithWellnessIncentiveYou pay100% untildeductibleis metYou pay100% untildeductibleis met 50 copayYou pay50%;Plan pays50% afterdeductible 45 copayYou pay40%;Plan pays60% afterdeductible 40 copayYou pay40%;Plan pays60% afterdeductibleWithoutWellnessIncentiveYou pay100% untildeductibleis metYou pay100% untildeductibleis met 80 copayYou pay50%;Plan pays50% afterdeductible 75 copayYou pay40%;Plan pays60% afterdeductible 70 copayYou pay40%;Plan pays60% afterdeductibleYou pay100% untildeductibleis metYou pay30%;Plan pays70% afterdeductibleYou pay50%;Plan pays50% afterdeductibleYou pay20%;Plan pays80% afterdeductibleYou pay40%;Plan pays60% afterdeductibleYou pay20%;Plan pays80% afterdeductibleYou pay40%;Plan pays60% afterdeductibleOutpatient SurgeryYou pay100% untildeductibleis metUrgent CareWithWellnessIncentive 60 copayYou pay100% untildeductibleis met 60 copayYou pay50%;Plan pays50% afterdeductible 55 copayYou pay40%;Plan pays60% afterdeductible 50 copayYou pay40%;Plan pays60% afterdeductibleWithoutWellnessIncentiveYou pay100% untildeductibleis metYou pay100% untildeductibleis met 90 copayYou pay50%;Plan pays50% afterdeductible 85 copayYou pay40%;Plan pays60% afterdeductible 80 copayYou pay40%;Plan pays60% afterdeductibleYou pay30%;Plan pays70% afterdeductibleYou pay30%;Plan pays70% afterdeductibleYou pay20%;Plan pays80% afterdeductibleYou pay20%;Plan pays80% afterdeductibleYou pay20%;Plan pays80% afterdeductibleYou pay20%;Plan pays80% afterdeductibleYou pay30%;Plan pays70% afterdeductibleYou pay50%;Plan pays50% afterdeductibleYou pay20%;Plan pays80% afterdeductibleYou pay40%;Plan pays60% afterdeductibleYou pay20%;Plan pays80% afterdeductibleYou pay40%;Plan pays60% afterdeductibleYou pay30%;Plan pays70% afterdeductibleYou pay50%;Plan pays50% afterdeductibleYou pay20%;Plan pays80% afterdeductibleYou pay40%;Plan pays60% afterdeductibleYou pay20%;Plan pays80% afterdeductibleYou pay40%;Plan pays60% afterdeductibleEmergency SurgeryYou pay100% untildeductibleis metYou pay100% untildeductibleis metInpatient Hospital StayYou pay100% untildeductibleis metYou pay100% untildeductibleis metChiropractic ServicesYou pay100% untildeductibleis metYou pay100% untildeductibleis metHearing Aids Now covered for dependents under age 18The benefit will pay up to 1,250 per individual, per hearing aid, with replacement covered every three years.Note: In Florida, Georgia, Kansas City, MO, New Hampshire, New Jersey, Oklahoma, Washington, D.C. and Wisconsin, coverage will beprovided by a BCBST alternate network.1234The High Deductible Plan deductible and out-of-pocket maximums include both medical and prescription expenses. Copays do notcount toward your deductible, but they do count toward your out-of-pocket maximum. See your Summary Plan Description (SPD)for more information.Medical services in the Basic, Standard and Maximum Plans are subject to a calendar-year deductible, not including the prescriptiondrug deductible. Copays do not count toward your deductible, but they do count toward your out-of-pocket maximum. See yourSummary Plan Description (SPD) for more information.Coverage of sigmoidoscopies and colonoscopies at 100% is subject to BCBST’s medical necessity guidelines. Diagnosticsigmoidoscopies and colonoscopies are subject to deductible and coinsurance.Office copay covers labs and X-rays.9
2021 Medical and Prescription (weekly rates)If you cover a spouse, in addition to the rate in the applicable table below, you will pay a: 125/month “Working Spouse Charge” if your spouse is eligible for employer medicalcoverage at his or her own job (other than Dollar General or self-employment). 50/month “Spouse Wellness Premium” if your spouse does not complete the BetterLife Health Assessment by the deadline noted within the email he or she will receive.(See page 6 for details.)High DeductibleWith Tobacco-Free Premium CreditWithout CreditEmployee Only 24.00 33.23Employee Spouse* 66.00 75.23Employee Child(ren) 60.55 69.78Employee Family* 99.57 108.81With Tobacco-Free Premium CreditWithout CreditEmployee Only 47.56 56.79Employee Spouse* 83.11 92.34Employee Child(ren) 69.98 79.21Employee Family* 116.30 125.53With Tobacco-Free Premium CreditWithout CreditBasicStandardEmployee Only 63.93 73.16Employee Spouse* 119.24 128.47Employee Child(ren) 98.45 107.68Employee Family* 167.09 176.32With Tobacco-Free Premium CreditWithout CreditEmployee Only 100.47 109.71Employee Spouse* 200.24 209.47Employee Child(ren) 169.41 178.64Employee Family* 277.90 287.13Maximum* These rates do not include the additional 125-per-month charge to cover a full-time working spouse who has access to otheremployer-provided medical coverage or 50-per-month Spouse Wellness Premium if your covered spouse chooses not to completea Health Assessment.10
Save Time and Money on Medical CareAccess the tools and resources to help you be a smart health care consumer.Health Support ProgramsIf you qualify, these programs are available at no extra cost to Health Plan participants!Get Relief from ChronicBack, Knee, Hip, Shoulderor Neck PainA personal health coach willtailor exercise, therapy andeducation for you from theprivacy and convenience ofyour own home. Participantsreport an average painreduction of 60% in as littleas 45 minutes per week!These programs are offeredby Hinge Health.Hypertension ProgramA health coach will assistyou with blood pressuremonitoring while clinicalcare professionals areavailable to help you withhypertension managementand education. This programis offered by Livongo.Note: Chronic pain is defined as painpersisting over 12 weeks.Diabetes Preventionand ManagementProgramsIf you have pre-diabetes ordiabetes, a personalized webportal will give you accessto health coaching andeducational materials, as wellas options for periodic reviewof progress and feedback.Depending on the program,you’ll receive unlimited freetest strips and lancets, anda new blood sugar meteror a “smart” scale to assistwith weight management.These programs are offeredby Livongo.Call 1-800-521-9919 or log in to BlueAccessSM to get connected with TeladocTelehealthAccess a doctor24/7 by phone oronline video — atno cost for all medical plans.Download the Teladoc app fromthe App Store or Google Play.Expert MedicalOpinion(through Teladoc)Receive peaceof mind froman expert second medicalopinion.BlueDistinctionCentersGet the bestquality care at thelowest price.ConvenientCareFind a primarycare doctor andlocate the urgentcare center nearest to your homeat bcbst.com/manage-my-plan.BCBSTNurselineNot sure whereto receive care?Get free advicefrom a nurse24/7.CostTransparencyToolFind out the costof health carebeforehand and get connectedwith in-network health care,which is often more affordable.11
Prescription DrugIf you elect a Dollar General medical plan, you’ll receive prescriptiondrug coverage as part of that plan.2021 Prescription Drug CoverageHigh Deductible*BasicStandardMaximumNANAPrescription Drug Deductible (for Brand-Name Drugs only)SingleWith Wellness IncentiveWithout Wellness IncentiveFamilyWith Wellness IncentiveWithout Wellness IncentiveMaintenanceMedicationsWith Wellness MedicalDeductibleNA 400 250 115(Brand-Name Drugs Only)(Brand-Name Drugs Only)(Brand-Name Drugs Only)NANANA 800 500 230(Brand-Name Drugs Only)(Brand-Name Drugs Only)(Brand-Name Drugs Only)Generic: 100%covered;Brand: 50%Generic: 100%covered;Brand: 50%Generic: 100%covered;Brand: 50%Generic: 100%covered;Brand: 50%Out-of-Pocket Maximum** (combined with Medical Out-of-Pocket Maximum)Single 7,150 7,150 7,150 2,875Family 13,300 14,300 14,300 5,750You pay 30%You pay 20%You pay 20% 150 100 50You pay 45%You pay 35%You pay 35% 200 150 75You pay 60%You pay 50%You pay 50% 350 250 150Generic DrugsCoinsuranceMax copay per30-day supplyYou pay 100% untildeductible is metPreferred Brand-Name DrugsCoinsuranceMax copay per30-day supplyYou pay 100% untildeductible is metNon-Preferred Brand-Name DrugsCoinsuranceMax copay per30-day supplyYou pay 100% untildeductible is met* For High Deductible Plan, prescription drug deductible is combined with medical deductible.** For all plans, prescription drug out-of-pocket maximums are combined with medical out-of-pocket maximums.Get tips to save time and money on prescription drugs on page 14.12
SpecialtyPharmacy ProgramStepTherapyPrescriptions for certain seriousconditions, such as hepatitis, cancer,rheumatoid arthritis, multiple sclerosis,hemophilia and HIV/AIDS, must befilled through the BCBST SpecialtyPharmacy Program. A BCBST SpecialtyPharmacy Benefit Manager will contactyou to participate in this mandatoryprogram. For more information, call1-800-521-9919.For brand-name medication drugsused to treat certain illnesses andconditions (such as COPD, asthma,chronic bronchitis, emphysema anddiabetes), choose a generic medicationfirst before using a brand-namemedication for the plan to cover theprescription cost. If you choose abrand-name drug first, you will beresponsible for 100% of the cost.Preferred step therapy allows youto choose a preferred brand-nameprescription drug or generic prescriptiondrug. If you choose a non-preferredbrand-name drug, you will pay 100%of the cost.13
Save Time and Money on Prescription DrugsHere are some tips to save time and money on prescriptions throughout the year.Take advantageof free or reducedcost maintenancemedications.If you complete theHealth Assessmentwhen you enroll inbenefits, you’ll receivefree generic medications and 50% offcovered brand-name medications forthe following conditions: Asthma, chronic obstructivepulmonary disease (COPD), diabetes,coronary artery disease (CAD) andcongestive heart failure (CHF).Use mail order forprescriptions.All maintenancemedicationsprescribed for 90days or more mustbe filled through mailorder or at CVS,Kroger, a Kroger-affiliate retail locationor any other participating DG90Network Provider after three 30-dayfills at a network retail location.Contact BCBST at 1-800-521-9919for a listing of approved pharmacies. Eligible therapeutic categoriesinclude: Statins, theophyllines, leukotrienes,calcium channel blockers, ACEinhibitors, diabetic medications,beta blockers and inhaled steroids.Find out if yourprescriptions areavailable as overthe-counter (OTC)medications.Some OTCmedications areexactly the same asprescription drugs and usually costsignificantly less. Talk to your doctoror pharmacist about which onesmight work for you.Find out if there isa cheaper genericalternative to yourmedication.Generic drugs offerthe lowest price.Talk to your doctoror call 1-800-521-9919to see if your medication has a genericalternative.You can also download theRx Savings Solutions mobileapp (available in the Apple AppStore and Google Play Store)to help you save money onyour prescriptions.14
Additional Benefits toProtect Your FamilyThese supplemental benefits can help protect you and your familywhen the unexpected happens.MetLife Legal PlanCovers legal advice andrepresentation for a wide range oflegal topics — from family matters tocourt appearances — with no deductibleor copay. It’s like having an attorney onretainer for about 4.11 per week.*!For more informationon each of these plans,including specificpolicy information, seethe plan brochures onthe Guides & Tutorialspage on DGWell.LifeLock IdentityTheft ProtectionGives you protection for one of yourmost valuable assets — your identity! Alsoreceive scores, monitoring and alerts acrossthree credit bureaus and more for 1.67/single or 3.35/family per week.Cancer Insurance**Critical Illness Insurance**Provides benefit paid directly toyou for costs associated withcancer treatment. Premium starts at 4.04 per week.Provides a lump-sum cash benefitpaid directly to you to help pay thecosts associated with the diagnosis of criticalillnesses like heart attack, stroke and organfailure for as low as 1.09 per s your eligible familymembers access to a doctor 24/7 byphone or video, for only 2.80 per week.Offers benefits for treatment ofaccidental off-the-job injuries likefractures, dislocations, burns and morefor as low as 1.73 per week.Hospital ConfinementInsuranceWhole LifeInsurance**Pays an admission benefit plus adaily benefit for each additional dayyou are hospitalized starting around 4.19 per week.Provides benefits for long-termcare that can help protect you andyour family for a lifetime starting around 4.00 per week.These policies pay you directly when you need it most. See policy information on DGme forspecific benefit details.*When using an in-network attorney.**Insurance products underwritten by Transamerica Life Insurance Company, Cedar Rapids, IA. This insurance may not beavailable in all jurisdictions. Limitations and exclusions apply. Refer to the policy, certificate and riders for complete details.15
DentalDollar General offers you a choice of two dental plans. Both plans allow you to see any provideryou want, but you’ll see the most savings when you choose a network provider.Your dental optionsPreventive OnlyComprehensive 1,000 1,500Covered at 100%Covered at 100%Restorative Services(fillings, extractions, oral surgery, root canals,periodontics)Not covered80%Major Services(crowns, inlays, onlays, dentures, implants)Not covered50%Annual Benefit Maximum (per person)Diagnostic and Preventive Services(oral exams, cleanings, X-rays)Bruxism AppliancesMouth GuardsNot coveredAdjustmentsSealantsOrthodontics(dependent children to age 19: 1,500 lifetimemaximum per child)One per 36 monthsOne per 12 months after six monthsof initial placementNot coveredOne per 60 months(up to age 19)Not covered50%2021 Weekly RatesPreventiveComprehensiveEmployee Only 1.63 6.03Employee Spouse 3.57 13.26Employee Child(ren) 2.93 11.28Employee Family 5.33 20.22Note: If you enroll in Dollar General’s Comprehensive Plan, there will be a 12-month waitingperiod before Major Services and Orthodontia are covered.16
VisionEye exams can help with early detection of conditions like glaucoma, hypertension and diabetesthat affect your overall health — not just the health of your eyes. Dollar General offers you achoice of two vision plans.Your vision optionsPreventive OnlyAnnual ExamOne per 12 workCovered at 100%Plan pays 40Covered at 100%Plan pays 40Not coveredNot covered 40 for standardcontacts; 10%discount forpremium contactsNot coveredContact Lens ExamEyeglass LensesFramesPlan payment variesby lens type: Single: 50 Bifocal: 70 Trifocal: 10535% discount iflenses and framesare purchased atthe same time20% discount iflenses and framesare purchasedseparatelyContact LensesDiabetic Care ServicesFollow-up ExamComprehensiveOne set per 12 monthsNot coveredPlan payment variesby lens type: Single: 40 copay Bifocal: 60 copay Trifocal: 80 copay 10 copayOne set every 24 monthsNot covered 130 allowance,20% discounton balance 75 allowance 80 allowance;Up to 210reimbursementfor medicallynecessary lensesVaries by service15% discount forconventional lensesNot coveredCovered at 100%if medicallynecessary; 105 allowancefor elective 20 copayNot coveredCovered at 100%2021 Weekly RatesPreventiveComprehensiveEmployee Only 0.21 0.93Employee Spouse 0.41 1.85Employee Child(ren) 0.43 1.95Employee Family 0.68 3.0617
Flexible SpendingAccounts (FSAs)If you are newly eligible for full-time benefits at Dollar General, you may choose to participate inthese accounts during the next annual enrollment period, with benefits effective January 1, 2022.FSAs can save you money on health care and dependent “day care” expenses. Your contributionsto these accounts are made on a pre-tax basis, reducing your taxable income and saving you money.When you need to pay for eligible care, you can use your FSA debit card (administered byHealthEquity).HealthCare FSADependent“Day Care”FSA Use for: Eligiblemedical, prescriptions, dental andvision out-of-pocket expenses foryou and your dependents. Use for: Day care and summercamp expenses for your child(ren)under age 13, or other qualifyingperson* to allow you to work, lookfor work or be a full-time student.This account may not be used forhealth care expenses for yourdependents. Contribute: Up to the IRS limit(which is 2,750 in 2021). Theannual amount you choose tocontribute to the Health Care FSAis immediately available uponenrollment to pay for eligibleexpenses — even though youcontribute with each paycheckthroughout the year. Contribute: Up to the IRS limit of 5,000 per year ( 2,500 if marriedand filing incom
eligibility date if a part-time employee, to enroll. Your selected benefit will become effective on the applicable benefits eligibility date, as noted in the enrollment platform. If you have questions regarding your eligibility or deadline to enroll, call the Benefits Service Center at 1-855-ASK-DGHR (1-855-275-3447). Eligible Dependents
