TGI Fridays Benefits Guide

A Guide
to Your
Benefits

2016

A GUIDE TO YOUR BENEFITS | 2013

ABC Company offers a comprehensive suite of benefits to promote health and financial security for you and
your family. This booklet provides you with a summary of your benefits. Please review it carefully so you
can choose the coverage that’s right for you.

Benefit Basics Qualified Life Events WHAT IS A DOMESTIC PARTNER?

As an ABC Company employee, you are Generally, you may change your benefit Your domestic partner is eligible for
eligible for benefits if you work at least elections only during the annual benefits if he or she has lived with you
30 hours per week. Benefits are effective enrollment period. However, you may for at least six months in a committed
on the first day of the month following change your benefit elections during the relationship and is not a relative. For
your date of hire. year if you experience a qualified life more information about domestic
event, including: partner benefits, [contact the HR
You may enroll your eligible dependents Department at xxx-xxx-xxxx.]
for coverage once you are eligible. Your  Marriage
eligible dependents include: You must notify Human Resources
 Divorce or legal separation within 30 days of the qualified life event.
 Your legal spouse Depending on the type of event, you
 Birth of your child may be asked to provide proof of the
 [Your domestic partner] event. If you do not contact Human
 Death of your spouse, Resources within 30 days of the qualified
 Your children up to age 26. [domestic partner] or event, you will have to wait until the
dependent child next annual enrollment period to make
Once your benefit elections become changes (unless you experience another
effective, they remain in effect until the  Adoption of or placement for qualified life event).
end of the year. You may only change adoption of your child
coverage within 30 days of a qualified For more information about your
life event.  Change in employment status benefits, [PROVIDE INSTRUCTIONS,
of employee, spouse/domestic INCLUDING A WEB SITE, AN
partner or dependent child EMPLOYEE HANDBOOK, OR OTHER
INFORMATION SOURCE HERE].
 Qualification by the Plan
Administrator of a child support
order for medical coverage

 Entitlement to Medicare or
Medicaid

Cost of Your Benefits

The Company pays the full cost of many of your benefits; you share the cost for others.
You pay the full cost for any voluntary benefits you elect.

Benefit Tax Treatment Who Pays

Medical Coverage Pre-tax The Company & You

Dental Coverage Pre-tax The Company & You

Vision Coverage Pre-tax You

Basic Life and Accidental Death & Dismemberment (AD&D) After-tax The Company
Insurance

Supplemental Life and Accidental Death & Dismemberment After-tax You
(AD&D) Insurance

Disability Coverage After-tax The Company

Flexible Spending Accounts Pre-tax You

Commuter Benefit Pre-tax You

401(k) Retirement Savings Plan Pre-tax The Company & You

Medical Coverage [Edit based on plan design]

The Company offers a choice of medical plan options so you can choose the plan that best meets your needs – and those of your
family. Each plan includes comprehensive health care benefits, including free preventive care services and coverage for prescription
drugs.

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A GUIDE TO YOUR BENEFITS | 2013

HRA Plan Name HSA Plan Name POS Plan Name

.Plan Provisions In-Network Out-of- In-Network Out-of- In-Network Out-of-
Network Network Network
Company Contribution to
HRA or HSA $500 / $1,000 $200 / $700 (not applicable)
(Individual/Family)
Annual Deductible $1,500 / $3,000 $500 / $1,000 / None $500 /
(Individual/Family) $1,000 $2,000 $1,000
Out-of-Pocket Maximum
(Includes Deductible) $3,500 / $7,500 / $1,000 / $4,000 / None $1,500 /
Lifetime Maximum $7,000 $15,000 $2,500 $8,000 $3,000

Preventive Care Unlimited Unlimited Unlimited

Primary Physician Office 100% 70% after 100% 70% after 100% 80% after
Visit deductible deductible deductible

Specialist Office Visit 90% after 60% after $25 copay 70% after $25 copay 80% after
deductible deductible deductible deductible
Inpatient Hospital Services
90% after 60% after $40 copay 70% after $40 copay 80% after
Outpatient Hospital deductible deductible deductible deductible
Services
90% after 60% after 90% after 70% after 100% 80% after
Urgent Care deductible deductible deductible deductible deductible

Emergency Room Care 90% after 60% after 90% after 70% after 100% 80% after
deductible deductible deductible deductible deductible
Prescription Drug
Deductible 90% after 60% after $40 copay 70% after $40 copay 80% after
(Individual/Family) deductible deductible deductible deductible
Retail Prescription Drugs
(30-day supply) 90% after 60% after $150 copay $125 copay
Generic deductible deductible
Brand Preferred
Brand Non-preferred None $100 / $200 None
Mail Order Prescription Waived for generic drugs
Drugs (90-day supply)
Generic $10 copay Not covered $10 copay Not covered $10/$30/$50 80%
Brand Preferred $30 copay $30 copay after copay
Brand Non-preferred $50 copay $50 copay ($10/$30/$50)

$20 copay N/A $20 copay N/A $20 copay N/A
$60 copay
$100 copay $60 copay $60 copay

$100 copay $100 copay

Important Notes
 This is a synopsis of coverage only; the benefits summary contains exclusions and limitations that are not shown here. Please
refer to the benefits summary for the full scope of coverage.

 In-network services are based on negotiated charges; out-of-network services are based on Reasonable & Customary (R&C)
charges.

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A GUIDE TO YOUR BENEFITS | 2013

Dental Coverage

Regular dental exams can help you and your dentist detect problems in the early stages
when treatment is simpler and costs are lower. Keeping your teeth and gums clean and
healthy will help prevent most tooth decay and periodontal disease, and is an important
part of maintaining your medical health.

The Company offers you a choice of XX dental plans: the [Dental Plan PPO Name] and the
[Dental Plan Number Two Name].

Plan Provision Dental Plan Name $50/$150 Dental Plan Name
100%, no deductible $2,000 100%, no deductible
Annual Deductible
(Individual/Family) 80% after deductible 80% after deductible

Annual Maximum (per person) 50% after deductible 50% after deductible

Diagnostic and Preventive Care: 50% after deductible
Includes cleanings, fluoride treatments, $1,500 lifetime maximum
sealants and x-rays

Basic Services:
Includes fillings, periodontics, scaling and
root planing, and oral surgery

Major Services:
Includes crowns, bridges and full and
partial dentures

Orthodontia
(Children only up to age 26)

Vision Coverage

The vision plan covers routine eye exams and also pays for all or a portion of the cost of

glasses or contact lenses if you need them.

Benefit In-Network Out-of-Network
Exam Max reimbursement up to $40
Hardware $10 copay
Frequency See below
• Exam $10 copay
• Lenses 24 months
• Frames 24 months 24 months
24 months 24 months
Frames 24 months
Covered 100% within the Max reimbursement up to $50
Lenses $50 wholesale allowance
• Single Vision Lenses (approximately $125 to $150 retail) Up to a maximum reimbursement of $40
• Bifocal Lenses Up to a maximum reimbursement of $50
• Trifocal Lenses Covered at 100% Up to a maximum reimbursement of $75
Covered at 100%
Medically Necessary Contact Lenses Covered at 100% Max reimbursement up to $300
Covered at 100% of
Elective Contact Lenses in lieu of Glasses reasonable & customary charges Same as in-network benefit

Up to $150 (copay doesn’t apply)

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A GUIDE TO YOUR BENEFITS | 2013

Flexible Spending Accounts

Flexible Spending Accounts (FSAs) are designed to save you money on your taxes. They work in a similar way to a savings account.
Each pay period, funds are deducted from your pay on a pre-tax basis and are deposited to your Health Care and/or Dependent Care

FSA. You then use your funds to pay for eligible health care or dependent care expenses.

Account Type Eligible Expenses Annual Benefit
Health Care FSA Contribution
Most medical, dental and vision care Saves on eligible
Dependent Care FSA expenses that are not covered by your Limits expenses not
health plan (such as copayments, covered by
coinsurance, deductibles, eyeglasses and Maximum insurance; reduces
doctor-prescribed over the counter contribution is your taxable income
medications) $2,500 per year
Reduces your
Dependent care expenses (such as day care, Maximum taxable income
after school programs or elder care contribution is
programs) so you and your spouse can work $5,000 per year
or attend school full-time ($2,500 if married
and filing separate
tax returns)

Important Information This is known as the “use it or lose it” reimbursed with the funds from the
About FSAs rule and it is governed by IRS account, and not when you file your
regulations. Note that FSA elections do income tax return at the end of the year.
Your FSA elections will be in effect from not automatically continue from year to
January 1 through December 31. Claims year; you must actively enroll each year. Save on Your Taxes
for reimbursement must be submitted
by March 31 of the following year. Please The Advantages of an FSA Here is an example of how much you can
plan your contributions carefully. Any save when you use the FSAs to pay for
money remaining in your account after With an FSA, the money you contribute your predictable health care and
March 31 will be forfeited. is never taxed—not when you put it in dependent care expenses.
the account, not when you are

With FSA Without FSA

Your taxable income $50,000 $50,000

Pre-tax contribution to Health Care and Dependent Care FSA $2,000 $0

Federal and Social Security taxes* $11,701 $12,355

After-tax dollars spent on eligible expenses $0 $2,000

Spendable income after expenses $36,299 $35,645

Tax savings with the Medical and Dependent Care FSA $654

*This is an example only, and may not reflect your actual experience. It assumes a 25% federal income tax rate marginal rate and a 7.7% FICA marginal rate. State and local

taxes vary, and are not included in this example. However, you will also save on any state and local taxes as well.

Does the FSA plan have the 2 ½ month grace period or the new carryover provision? Update this
paragraph with the text outlined in the FSA language – three scenarios document posted to the
Employee Benefits Enrollment Template folder. REMEMBER TO DELETE THIS CALLOUT BOX.

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A GUIDE TO YOUR BENEFITS | 2013

Life and Accidental Death & Dismemberment
(AD&D) Insurance Coverage

Life insurance is an important part of The Company provides Basic Life and
your financial security, especially if AD&D Insurance to all eligible employees
others depend on you for support. at no cost to you. This benefit includes:
Accidental Death & Dismemberment
(AD&D) insurance is designed to provide  One times annual basic
a benefit in the event of accidental death earnings, up to a maximum
or dismemberment. benefit of $XX ($XX minimum
benefit).

 PROVIDE MORE DETAIL IF
REQUIRED

Disability Insurance Coverage

The goal of the Company’s Disability Short-Term Disability (STD): Long-Term Disability (LTD):
Insurance Plans is to provide you with
income replacement should you become  Covers 66.67% of your weekly  Covers 66.67% of your weekly
disabled and unable to work due to a pre-disability earnings -- up to a pre-disability earnings -- up to a
non-work-related illness or injury. The $2,770 weekly maximum. $12,000 monthly maximum.
Company provides eligible employees
with disability income benefits at no cost  Benefits begin on the eighth day  Benefits begin after ninety days
to you. of injury or illness and continue of disability or illness and
to the earlier of recovery or continue to the earlier of
ninety days. recovery or five years.

Business Travel Accident Insurance Coverage

Business Travel Accident Insurance  24-hour worldwide business Please contact [Fill in this information]
covers you in the event of accidental travel protection for details about coverage.
death or dismemberment when traveling
for business. In addition, this coverage  Travel assistance services
includes:
 Emergency medical evacuation

Commuter Benefits Program

The Commuter Benefits Program commuter-related parking expenses on a For enrollment or changes, determine
provides you with pre-tax savings for pre-tax basis. Funds are not your monthly transit and/or parking
specific commuter expenses. You may transferrable. Transit amounts may only expenses, and contact [Insert basic
contribute up to $125 per month from be spent on mass transit and parking information].
your pay for mass transit expenses and amounts may only be spent on eligible
up to $240 per month for eligible parking.

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Employee Assistance Program (EAP)

Sometimes life can be challenging. EAP counselors will assist you with Our provider is [Name of carrier}. If you
That’s why the Company provides an concerns such as: need help or guidance, you may reach
employee assistance program (EAP) to out to the EAP at [Phone number] or
all eligible employees -- at no cost to you.  Marital and relationship issues [website].
The EAP is designed to provide prompt,
confidential help with a range of personal  Alcohol and drug abuse
and family issues that may affect all of us
from time to time. You or a member of  Stress management
your household (spouse or domestic
partner, dependent children, parents and  Family/parenting problems
parents-in-law) receive up to three free
counseling sessions with an EAP  Work relationships
Professional.
 Legal assistance

 Wellness information

 And much more

401(k) Retirement Savings Plan

The ABC Company 401(k) Retirement Employee Contributions For More Information
Savings Plan offers a convenient way to
save for your future through payroll Contributions from your pay are made For additional details about the 401(k)
deductions. on a pre-tax basis -- up to the IRS annual Retirement Savings Plan or to enroll or
limit. If you are 50 years of age or older, change your contribution rates or
Eligibility (or if you will reach age 50 by the end of investment elections, please refer to
the year), you may make a catch-up [provide more information here].
You are eligible to participate in the plan contribution in addition to the normal
as of the first day of the month following IRS annual limit.
one month of service with the
Company. Vesting

Vesting refers to your right of ownership
to the money in your account. You are
immediately vested in all contributions
and earnings.

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A GUIDE TO YOUR BENEFITS | 2013

Contact Information

Plan Whom To Call Phone Number Website
Medical Plan Aetna xxx-xxx-xxxx www.aetna.com
Health Reimbursement
Account (HRA)

Dental Plan
Vision Plan

Flexible Spending Accounts

Life & AD&D Insurance

Short-Term & Long-Term
Disability Insurance

Business Travel Accident
Insurance

Commuter Benefits

Employee Assistance
Program (EAP)

401(k) Retirement Savings
Plan

About this Guide by master policies, contracts and plan ABC Company reserves the right to
documents. Any discrepancies between amend, suspend or terminate any
This benefit summary provides selected information provided through this benefit plan, in whole or in part, at any
highlights of the ABC Company summary and the actual terms of the time. The Plan Administrator has the
employee benefits program. It is not a policies, contracts and plan documents authority to make these changes.
legal document and shall not be are governed by the terms of these
construed as a guarantee of benefits nor policies, contracts and plan documents.
of continued employment at the
Company. All benefit plans are governed

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