2024 WELLNESS AND BENEFITS GUIDE
FULL TIME EMPLOYEES
2
TABLE OF CONTENTS
TABLE OF CONTENTS
3 CUSTOMER SERVICE INFORMATION
4 A MESSAGE FROM
RUBY TUESDAY
5 ELIGIBILITY
6 MEDICAL INSURANCE OPTIONS
7 BCBST MEDICAL PLANCOMPARISON
8 BCBST MEDICAL
INSURANCE INFO
9 TELADOC
12 ELIXIR PHARMACY –
PAYER MATRIX
13 EMPLOYEE OUT-OF-POCKET COST
CALCULATION EXERCISE
14 MEC MEDICAL INSURANCE INFO
16 PAN-AMERICAN MEC BENEFITS*
18 MEDICAL WEEKLY RATES*
19 HEALTH SAVINGS ACCOUNT
20 DEPENDENT CARE FSA
21 PAYFLEX MOBILE
®
APP
22 DENTAL INSURANCE
23 VISION INSURANCE
24 LINCOLN EMPLOYEE
ASSISTANCEPROGRAM
25 LIFE AND AD&D
25 DISABILITY INSURANCE
26 VOLUNTARY LIFE AND AD&D
27 VOLUNTARY DISABILITY
28 VOLUNTARY CRITICAL ILLNESS
29 VOLUNTARY ACCIDENT COVERAGE
30 VOLUNTARY LEGAL PLAN
31 VOLUNTARY PET INSURANCE
32 ADDITIONAL VOLUNTARY BENEFITS
33 401(k) RETIREMENT PROGRAM
34 HELPFUL TERMINOLOGY
35 MAINE-ONLY MEC
MEDICAL PLAN
38 REQUIRED NOTICES
If you (and/or your dependents) have Medicare or will become
eligible for Medicare in the next 12 months, a Federal law gives you
more choices about your prescription drug coverage. Please see
page 43 for more details.
3
CUSTOMER SERVICE
INFORMATION
TYPE OF
COVERAGE
CARRIER
PHONE
NUMBER
WEBSITE / E-MAIL
Medical EPO/PPO
BlueCross BlueShield
of Tennessee, Inc.
800-565-9140 www.BCBST.com/member
Medical EPO/PPO
Pharmacy
Elixir 800-361-4542 www.elixirsolutions.com/
Medical Indemnity Pan-American 800-999-5382 mypalic.com
Medical Indemnity
Pharmacy
RxEDO 888-879-7336 www.RxEDO.com
Dental PPO
BlueCross BlueShield
of Tennessee, Inc.
800-565-9140 www.BCBST.com/member
Vision
BlueCross BlueShield
of Tennessee, Inc.
877-342-0737 www.BCBST.com
Accident and
Critical Illness
Lincoln 877-275-5462 www.lincolnfinancial.com/public/individuals
Life, Short and
Long-Term Disability
Lincoln 877-275-5462 www.lincolnfinancial.com/public/individuals
Employee
Assistance Program
(EAP)
Lincoln 833-475-0980
GuidanceResources.com
Username: LFGNY
Password: LFGNY1
Savings Accounts PayFlex 844-729-3539 www.mypayflex.com
Qualified Life Events Ruby Tuesday
800-325-0755,
Opt. 4
benefitsadministration@rubytuesday.com
401(k) Retirement Principal 800-547-7754 www.principal.com
Identity Theft Allstate 855-821-2331 Allstate.com
Term Life Chubb 866-324-8222 Chubb.com
Legal Services MetLife 800-821-6400 www.legalplans.com
Pet Insurance Nationwide 877-738-7874 benefits.petinsurance.com/rubytuesday
4
A MESSAGE FROM
RUBY TUESDAY
At Ruby Tuesday we recognize our ultimate success depends on our talented and dedicated workforce.
Our goal is to provide a comprehensive program of competitive benefits to attract and retain the best
employees available. Through our benefits programs we strive to support the needs of our employees
and their dependents by providing a benefit package that is easy to understand, easy to access, and
aordable for all our employees. This guide will help you choose the type of plan and level of coverage
that is right for you.
You can also access overviews of our benefit plans at http://benefits.rubytuesday.com/
All benefit elections made during the annual open enrollment are eective January 1, 2024 through
December 31, 2024. Changes to your benefit elections cannot be made during the plan year, unless
you experience a qualifying life event.
See next page for examples of qualifying life events.
5
ELIGIBILITY
ELIGIBLE EMPLOYEES
You may enroll in the Ruby Tuesday Employee Benefits Program if you are an exempt employee or a non-exempt,
full-time employee who averages at least 30 hours worked per week for the past 12 months.
ELIGIBLE DEPENDENTS
If you are eligible for our benefits, then your dependents are too. In general, eligible dependents include your
spouse, domestic partner, and children up to age 26. If your child is mentally or physically disabled, coverage
may continue beyond age 26 once proof of the ongoing disability is provided. See the legal notices for more
information.
WHEN COVERAGE BEGINS
Newly hired employees and dependents will be eective in Ruby Tuesday’s benefits programs on the first day of
the month following the date of hire beginning January 1, 2024.
OPEN ENROLLMENT
With few exceptions, Open Enrollment is the only time of year when you can make changes to your
benefits plan. During Open Enrollment, you can:
•
Add, change, or delete coverage
•
Add, or drop dependents from coverage
QUALIFYING LIFE EVENTS
Family Status Change:
A change in family status is a change in your personal life that may impact your eligibility or dependent’s
eligibility for benefits. Examples of some family status changes include:
•
Change of legal marital status
•
Change in number of dependents
•
Change in employment or job status (spouse loses job, etc.)
If such a change occurs, you must make the changes to your benefits within 30 days of the event date.
Documentation will be required. Failure to request a change of status within 30 days of the event may result in
loss of coverage.
6
MEDICAL INSURANCE OPTIONS
As a Ruby Tuesday employee, you have the choice of the following medical plans through BlueCross
BlueShield of Tennessee, Inc. BCBST partners with more than 95% of hospitals, doctors, and
specialists nationwide.
HRA PREMIER CARE PLAN
This plan has a Health Reimbursement Account
(HRA) provided by Ruby Tuesday. It provides
$2000 for Employee Only and $4000 for
Employees covering dependents. These dollars
can be used up front to cover expenses that
would typically be subject to the deductible. In
other words, the first $2000/$4000 is covered
by the HRA. Oce visits, lab work, Urgent Care,
Emergency Room and other expense subject to
the deductible can be paid for 100% with your
HRA until you’ve exhausted the funds. For most
employees this means you will never have to use
your own money to pay for medical treatment.
The HRA will be administered by Blue Cross Blue
Shield and will help oset the costs for qualified
in-network deductible expenses incurred by
you or a covered family member. The money
spent in your HRA counts toward meeting your
deductible; prescription drug copays are not
reimbursable through your HRA.
While this is the highest premium plan with a
$2800 annual deductible you can use the HRA
to meet the majority of your deductible. Once
your HRA funds have been exhausted, you
will be responsible for meeting the remainder
of your calendar year deductible. After the
deductible has been satisfied, the medical plan
will pay 80% of the allowable charges, and you
will be responsible for 20% up to the out-of-
pocket maximum. After that, the plan will pay
100% of covered expenses for the remainder
of the calendar year. Your HRA balance will
reset each year on January 1. Your network
accessibility is not limited, so you are able to
work with providers In-and-Out of Network, and
you pay co-pays for doctor visits and Rx.
HSA HIGH DEDUCTIBLE (HIGH-D)
This plan has the lowest premium and a $3,200
(Individual) annual deductible. Your network
accessibility is limited to In-Network Providers,
and you pay the full cost of your Medical/Rx
expenses until the deductible is met.
HSA LOW DEDUCTIBLE (LOW-D)
This is the average premium plan, and your annual
deductible is $1,750 (Individual). Your network
accessibility is not limited, so you are able to work
with providers In-and-Out of Network. You pay
the full cost of your Medical/Rx expenses until the
deductible is met.
Ruby Tuesday is contributing up to a $500 HSA
match per employee enrolled in the High-D and
Low-D HSA qualified plans. So, whether you
are enrolled in individual coverage, employee +
spouse coverage, employee + child(ren) coverage,
or family coverage, you get up to a $500 match
per year deposited tax free into the HSA divided
into two deposits - one in the first half of the year
and one in the second half of the year.
PLEASE NOTE: The match amount counts toward
your total IRS limit for the year.
PAN-AMERICAN MEC PLANS*
There are two MEC plan options with
Pan-American. These plans cover preventative
services with limited hospital indemnity coverage.
With either plan, there is no deductible or
coinsurance. Members using providers are
restricted to the First Health PPO network.
All members may visit providerlocator.com/palicfh
or call 888-561-5759 for a list of in-network
providers. See page 14 for additional information.
*Employees residing in Maine are oered an alternative MEC
plan. Please see page 35 for Maine-Only MEC coverage.
7
BCBST MEDICAL
PLANCOMPARISON
Ruby Tuesday oers the choice between two HSA medical plans and a Medical PPO through BlueCross
BlueShield of Tennessee, Inc., or two Minimum Essential Coverage Plan options through Pan-American.
Company Highlights of the medical plans are listed below. The grid below outlines the member share.
BCBST PLANS
BENEFIT COVERAGE
HRA PREMIER
CARE PLAN - PPO
HIGH D – EPO HSA LOW D – PPO HSA
IN-NETWORK
OUT-OF-
NETWORK
IN-NETWORK
OUT-OF-
NETWORK
IN-NETWORK
OUT-OF-
NETWORK
ANNUAL DEDUCTIBLE
Individual $2,800 $6,450 $3,200 N/A $1,750 $3,500
Family $8,400 $19,350 $6,400 N/A $3,500 $7,000
Coinsurance 20% 40% 30% N/A 20% 50%
SPENDING ACCOUNT
Type HRA HSA HSA
Amount $2,000 $500 $500
MAXIMUM OUT-OF-POCKET
Individual $6,450 $9,600 $6,450 N/A $6,450 $7,000
Family $12,900 $19,200 $12,900 N/A $12,900 $14,000
PHYSICIAN OFFICE VISIT
Primary Care
Deductible +
Coinsurance
40% of the
Maximum
Allowable
Charge*
30%* N/A
20%*
50% of the
Maximum
Allowable
Charge*
Specialty Care
100%
N/A
Preventive Care 100%
Not
Covered
100%
DIAGNOSTIC SERVICES
X-ray & Lab Tests
20%*
40% of the
Maximum
Allowable
Charge*
30%*
Not
Covered
20%*
50% of the
Maximum
Allowable
Charge*
Complex Radiology
Inpatient Facility Charges
Outpatient Facility & Surgical
Charges
Urgent Care Facility
Emergency Room Facility
Charges
100% after $300 copay
per visit, then 20%*
30%* 20%*
MENTAL HEALTH / SUBSTANCE ABUSE
Inpatient
20%*
40% of the
Maximum
Allowable
Charge*
30%* Not covered 20%*
50% of the
Maximum
Allowable
Charge*
Outpatient
OTHER SERVICES
Chiropractic 20%*
50% of the
Maximum
Allowable
Charge*
30%* Not covered 20%*
50% of the
Maximum
Allowable
Charge*
* After deductible
Note: HRA Premier Plan includes access to Health Reimbursement Account (HRA) fully funded by Ruby Tuesday and
administered by BCBST. Ruby Tuesday will fund $2,000 toward your HRA; if you have a covered family member on your plan,
Ruby Tuesday will fund $4,000 upon enrollment in the HRA Premier medical plan. You will receive ID cards once enrolled in the
BCBST plans.
8
BCBST MEDICAL
INSURANCE INFO
AT THE DOCTOR’S OFFICE
It’s recommended that you choose an
in-network primary care physician (PCP) for your
medical coverage, even though it is not required
for plans that include out of network benefits.
A PCP can be your Family Practitioner, Internist,
General Medicine, Pediatrician, or an OB/GYN
(Obstetrician & Gynecologist). Each member of
your family may have a dierent PCP.
If you are newly enrolling in medical benefits,
make an appointment with your PCP, even if
you’re NOT sick once the plan year has begun.
This relationship will set the foundation for
staying healthy—today and well into the future.
NETWORK PROVIDE/FACILITY
SEARCH
To locate a network provider, call 1-800-565-9140
or visit bcbst.com/get-care/find-care.
•
Find doctors, dentists, hospitals, and other health
care providers
•
Get cost estimates for over 1,600 common
medical procedures
Make sure that your provider or facility is
in-network.
MEMBER SERVICE PORTAL
Your medical carrier’s member portal is your
access to secure, personalized services with
interactive health tools built around you, your
benefits, and your health. Access the BCBST portal
at www.bcbst.com/login/member/ Once you are
registered your personal health information will be
available to you 24/7, including:
•
Finding care
•
Managing prescriptions
•
Managing claims
•
Staying healthy
•
Getting coverage and cost details
Need your health data on the run? Download
your free carrier app from the App Store or
Google Play. Use your mobile device to search
for doctors, hospitals and more! Just search for
BCBSTennessee.
BLUECROSS BLUESHIELD HEALTH
CONCIERGE
Your BlueCross BlueShield Concierge is ready to speak
with you at our toll-free number from 8 a.m. to 6 p.m.,
Monday through Friday. Simply call the number on
your BlueCross BlueShield member ID card.
PREVENTIVE CARE
You and your family have access to a wide
range of preventive services under the
Aordable Care Act. These services are
100% covered by your medical plan when
using in-network providers. For more
details about the covered services please
visit www.healthcare.gov/coverage/
preventive-care-benefits.
Routine physicals (age 18+)
or pediatric exams (birth to
age 17)
Well-woman exams
Blood pressure screening
for adults and children
Immunizations for
adults and children
COMMON PREVENTIVE
SERVICES INCLUDE:
9
BCBST MEDICAL
INSURANCE INFO
TELADOC
TELADOC IS DEDICATED TO MAKING HEALTHCARE BETTER, FASTER
AND EASIER
Teladoc lets you talk with a doctor anytime, anywhere, through phone or online video consults. Teladoc
is dedicated to improving member experiences by continually oering more health options and easier
ways to access care.
MORE HEALTH CARE OPTIONS
DERMATOLOGY BEHAVIORAL HEALTH
EASIER AND BETTER SERVICE
HRA PREMIER CARE PLAN – PPO:
Flat $25 copay
Millions of Americans suer from common
skin problems, many of which are easily
treatable. Get the skin care you need.
Teladoc doctors can provide advice,
recommendations and referrals for
whatever is on your mind.
MOBILE APP
The Teladoc
member app
gives you
24/7/365
access to a
doctor through
the convenience
of your mobile
devices.
ADVANCED
SCHEDULING
Now you have
the choice to
talk with the first
available doctor
or to schedule a
consult at a time
that fits your
schedule.
TYPE OF VISIT MEMBER COST
General Health Visit $55
Mental Health Visit $90
Dermatology Visit $85
TYPE OF VISIT MEMBER COST
General Health Visit $55
Mental Health Visit $90
Dermatology Visit $85
HIGH D – EPO HSA:
LOW D – PPO HSA:
TALK TO A DOCTOR ANYTIME
Teladoc.com
Facebook.com/Teladoc
800-Teladoc
Teladoc.com/mobile
10
TELADOC
®
MEMBER FREQUENTLY ASKED QUESTIONS
WHAT IS TELADOC?
Teladoc is the first and largest provider of telehealth
medical consults in the United States, giving you
24/7/365 access to quality medical care through
phone and video consults.
WHO ARE THE TELADOC DOCTORS?
Teladoc doctors are U.S. board certified in Internal
Medicine, Family Practice, or Pediatrics. They
average 15 years practice experience, are licensed
in your state, and incorporate Teladoc into their day-
to-day practice as a way to provide people
with convenient access to quality medical care.
DOES TELADOC REPLACE MY
DOCTOR?
No. Teladoc does not replace your primary care
physician. Teladoc should be used when you need
immediate care for non-emergent medical issues.
It is an aordable, convenient alternative to urgent
care and ER visits.
WHAT KIND OF MEDICAL CARE DOES
TELADOC PROVIDE?
When requesting a consult, you can choose between
general medical, behavioral health or dermatology.
WHAT CONSULT METHODS ARE
AVAILABLE?
You can talk with a Teladoc doctor via a phone
consult, video consult within the secure member
portal, or video consult within the Teladoc mobile app.
HOW DO I SET UP MY TELADOC
ACCOUNT?
Setting up your account is a quick and easy process
online. Visit the Teladoc website and click “Set Up
Account”. Follow the online instructions.
HOW DO I REQUEST A CONSULT TO
TALK TO A DOCTOR?
Visit the Teladoc website, log into your account and
click “Request a Consult”. You can also call Teladoc
to request a consult by phone.
HOW QUICKLY CAN I TALK TO THE
DOCTOR?
A doctor will call you back in 16 min, on average.
If you miss the doctor’s call, whether you are
away from the phone or you have anonymous
call blocker on, you will be returned to the
bottom of the waiting list. The consult request is
cancelled if you miss three calls.
IS THERE A TIME LIMIT WHEN
TALKING WITH A DOCTOR?
There is no time limit for consults.
CAN TELADOC DOCTORS WRITE A
PRESCRIPTION?
Yes, Teladoc doctors can prescribe short-term
medication for a wide range of conditions when
medically appropriate. Teladoc doctors do not
prescribe substances controlled by the DEA, non-
therapeutic and/or certain other drugs which may
be harmful because of their potential abuse.
HOW DO I PAY FOR A
PRESCRIPTION CALLED IN BY
TELADOC?
When you go to your pharmacy of choice to pick
up the prescription, you may use your health/
prescription insurance card to help pay for the
medication. You will be responsible for the co-
pay based on the type of medication and your
plan benefits.
CAN I PROVIDE CONSULT
INFORMATION TO MY DOCTOR?
Yes. You have access to your electronic medical
record at anytime. Download a copy online from
your account or call Teladoc and ask to have
your medical record mailed or faxed to you.
11
PRESCRIPTION DRUG COVERAGE FOR MEDICAL PLANS
Our Prescription Drug Program is coordinated through Elixir. Your cost is determined by the tier
assigned to the prescription drug product. Products are assigned as Generic, Preferred, Non-Preferred
or Specialty Drugs. After you are enrolled, you will receive a separate card for pharmacy benefits, you
can register to receive them here.
Ruby Tuesday Rx Bin Number: 009893
BCBST PLANS
BENEFIT COVERAGE
HRA PREMIER CARE
PLAN – PPO
HIGH D – EPO HSA LOW D – PPO HSA
IN-NETWORK
OUT-OF-
NETWORK
IN-NETWORK
OUT-OF-
NETWORK
IN-NETWORK
OUT-OF-
NETWORK
RETAIL PHARMACY (30 DAY SUPPLY)
Generic (Tier 1) $15 copay
50% of the
Maximum
Allowable
Charge*
$10 copay*
50% of the
Maximum
Allowable
Charge*
$10 copay*
50%
of the
Maximum
Allowable
Charge*
Preferred (Tier 2) $40 copay 75%* 75%*
Non-Preferred (Tier 3) $75 copay
Greater of
75% or
$400
deductible
Greater of
75% or
$400
deductible
Preferred Specialty (Tier 4)
Greater
of 75% or
$400
deductible
MAIL ORDER PHARMACY (90 DAY SUPPLY)
Generic (Tier 1) $40 copay $30 copay* $30 copay*
Preferred (Tier 2) $120 copay 75%* 75%*
Non-Preferred (Tier 3) Greater of 75% or $1,200 Greater of 75% or $1,200
Greater of 75% or
$1,200
Preferred Specialty (Tier 4) Not Covered Not Covered Not Covered
* After deductible
12
ELIXIR PHARMACY –
PAYER MATRIX
We are here to be your trusted patient advocate!
Payer Matrix is part of the pharmacy plan, Elixir Pharmacy. Payer Matrix is a patient advocacy group
that wants to help you save money on your specialty medications. If eligible for a discount on your
prescription medications, your personalized care coordinator will guide you through every step and will
be there if you have any questions along the way!
WHAT YOUR CARE COORDINATOR DOES FOR YOU
•
Patient assistance program guidance
•
Keep everything on-time
•
Hands-on paperwork
•
Dispense notifications
•
Scheduling assistance
•
Program research
•
Personalized custom care
•
Your own dedicated care coordinator
PAYER MATRIX ROAD MAP
Welcome Call
Your care
coordinator will
reach out to you to
understand your
needs.
Onboarding
Complete consent
and HIPAA forms.
Research available
programs
Our coordinator
takes your personal
case and finds
possible matches for
your treatment plan.
Enrollment and
clinical review
We work with your
physician to ensure
your treatment
plan is fulfilled
and application is
completed.
Program fulfilled
Once your
medication is
shipped we monitor
and confirm
dispenses each
month according to
your treatment plan.
LEARN MORE ABOUT US TODAY.
Visit our website at
www.payermatrix.com
13
EMPLOYEE OUT-OF-POCKET COST
CALCULATION EXERCISE
Summarized below are four scenarios outlining various claimant utilization examples when enrolled in
one of the BCBST medical plans.
CLAIM EXAMPLE: CLAIMANT #1 CLAIM EXAMPLE: CLAIMANT #2
EXAMPLE COSTS
COUNT
ALLOWED
COST PER
TOTAL COUNT
ALLOWED
COST PER
TOTAL
Doctor oce visits 3 $93.00 $279.00 15 $93.00 $1,395.00
Lab Charges (subj to Deductible &
Coinsurance except in PPO)
3 $50.00 $150.00 6 $50.00 $300.00
RX Generic cost AVG $25 per script 5 $25.00 $125.00 7 $25.00 $175.00
RX Top Used brand AVG $75 per script 0 $35.00 $0.00 3 $75.00 $225.00
MRI (subj to Deductible &
Coinsurance except in 1000 PPO)
0 $700.00 $0.00 0 $700.00 $0.00
Hospital days inpatient (subj to
Deductible & Coinsurance)
0 $1,900.00 $0.00 0 $1,900.00 $0.00
Total Claims $554.00 $2,095.00
CLAIMANT #1 CLAIMANT #2
HRA
PREMIER
LOW D
HSA
HIGH D
HSA
HRA
PREMIER
LOW D
HSA
HIGH D
HSA
HRA / HSA Payment $ 286 $ 500 $ 500 $ 1,695 $ 500 $ 500
OV Copays (2 PCP) $ – $ – $ – $ – $ – $ –
RX Copays $ 75 $ – $ – $ 225 $ – $ –
Deductible (less HRA and HSA) $ – $ 54 $ 54 $ – $ 1,250 $ 1,795
Coinsurance $ – $ – $ – $ – $ 69 ($ 2,095)
Employee Pays/Total OOP $ 75 $ 54 $ 54 $ 225 $ 1,319 $ 1,795
CLAIM EXAMPLE: CLAIMANT #3 CLAIM EXAMPLE: CLAIMANT #4
COUNT
ALLOWED
COST PER
TOTAL COUNT
ALLOWED
COST PER
TOTAL
Doctor oce visits 12 $93.00 $1,116.00 20 $93.00 $1,860.00
Lab Charges (subj to Deductible &
Coinsurance in PPO)
4 $50.00 $200.00 4 $50.00 $200.00
RX Generic cost AVG $25 per script 7 $25.00 $175.00 20 $25.00 $500.00
RX Top Used brand AVG $75 per script 8 $75.00 $600.00 10 $75.00 $750.00
MRI (subj to Deductible &
Coinsurance except in 1000 PPO)
1 $700.00 $700.00 2 $700.00 $1,400.00
Hospital days inpatient (subj to
Deductible & Coinsurance)
3 $2,000.00 $6,000.00 13 $2,000.00 $26,000.00
Total Claims $8,791.00 $30,710.00
CLAIMANT #3 CLAIMANT #4
HRA
PREMIER
LOW D
HSA
HIGH D
HSA
HRA
PREMIER
LOW D
HSA
HIGH D
HSA
HRA / HSA Payment $ 2,000 $ 500 $ 500 $ 2,000 $ 500 $ 500
OV Copays (2 PCP) $ – $ – $ – $ – $ – $ –
RX Copays $ 425 $ – $ – $ 700 $ – $ –
Deductible (less HRA and HSA) $ 800 $ 1,250 $ 2,500 $ 800 $ 1,250 $ 2,700
Coinsurance $ 1,043 $ 1,408 $ 1,737 $ 5,332 $ 5,792 $ 8,313
Employee Pays/Total OOP $ 2,268 $ 2,658 $ 4,237 $ 6,450 $ 6,450 $ 6,650
14
•
Prescription Benefits
•
PPO Network Information
•
Account Management
•
Claims
•
And more!
MEC MEDICAL INSURANCE INFO
PanaBridge Advantage Plans provide a combination of Minimum Essential Coverage (MEC) and a limited
hospital indemnity plan. Employees residing in Maine are oered an alternative MEC plan. Please see page 35
for Maine-Only MEC coverage.
BENEFIT DESCRIPTION PLAN 1 PLAN 2
HOSPITAL ADMISSION INDEMNITY BENEFIT
• Pays in addition to hospital indemnity
• Once per admission, once per diagnosis
• Benefit will not be payable for the same or
related injury or illness
$1,000 first day when admitted as an inpatient
into a hospital room
$1,500 first day when admitted as an inpatient
into a hospital room
HOSPITAL INDEMNITY BENEFIT
• Must be admitted as an inpatient into a
hospitalroom
• If hospital confinement falls into a category
below a dierent maximum applies
$400 per day
Overall calendar year max subject to 10 day(s)
total for any inpatient stay in a hospital
$600 per day
Overall calendar year max subject to 10 day(s)
total for any inpatient stay in a hospital
Intensive Care
If the participant is confined in a hospital intensive
care unit
$800 per day
Up to 5 day(s) calendar year max
(applied to overall calendar year max)
$1,200 per day
Up to 5 day(s) calendar year max
(applied to overall calendar year max)
Substance Abuse
Must be diagnosed and admitted as an inpatient in
a substance abuse unit
$200 per day
Up to 5 day(s) calendar year max
(applied to overall calendar year max)
$300 per day
Up to 5 day(s) calendar year max
(applied to overall calendar year max)
Mental Illness
Must be diagnosed and admitted as an inpatient
into a mental illness unit
$200 per day
Up to 10 day(s) calendar year max
(applied to overall calendar year max)
$300 per day
Up to 10 day(s) calendar year max (applied to
overall calendar year max)
Skilled Nursing Facility
Must be admitted in skilled nursing facility following
a covered hospital stay of at least 3 days
$200 per day
Up to 7 day(s) calendar year max
(applied to overall calendar year max)
$300 per day
Up to 7 day(s) calendar year max
(applied to overall calendar year max)
DOCTOR’S OFFICE BENEFIT
Benefit pays one benefit per day if the patient is
seen by a doctor for an illness or injury
$80 per day
4 day(s) per calendar year
$100 per day
4 day(s) per calendar year
OUTPATIENT DIAGNOSTIC LABS
• Includes glucose test, urinalysis, CBC, andothers
• When hospital confinement is not required and
the test is ordered or performed by a doctor
$20 per day
3 day(s) per calendar year
$20 per day
3 day(s) per calendar year
OUTPATIENT DIAGNOSTIC RADIOLOGY
• Includes chest, broken bones, and others
• When hospital confinement is not required and
the test is ordered or performed by a doctor
$70 per day
2 day(s) per calendar year
$70 per day
2 day(s) per calendar year
OUTPATIENT ADVANCED STUDIES
• Includes CT Scan, MRI, and others
• When hospital confinement is not required and
the test is ordered or performed by a doctor
$250 per day
2 day(s) per calendar year
$250 per day
2 day(s) per calendar year
INPATIENT SURGICAL BENEFIT
• Surgery must be performed due to an illness or
injury as an inpatient stay in a hospital
• Minor surgical procedures are excluded
$225 per day
1 day(s) per calendar year
$300 per day
1 day(s) per calendar year
INPATIENT ANESTHESIA BENEFIT
25% of the amount paid under the inpatient
surgicalbenefit
$56.25 per day
1 day(s) per calendar year
$75.00 per day
1 day(s) per calendar year
OUTPATIENT SURGICAL BENEFIT
• Surgery must be performed due to an illness or
injury at an outpatient surgical facility center or
hospital outpatient surgical facility
• Minor surgical procedures are excluded
$112.50 per day
1 day(s) per calendar year
$150 per day
1 day(s) per calendar year
OUTPATIENT ANESTHESIA BENEFIT
25% of the amount paid under the outpatient
surgical benefit
$28.13 per day
1 day(s) per calendar year
$37.50 per day
1 day(s) per calendar year
AMBULANCE SERVICES
Pays one benefit per day for emergency ground, air,
and water ambulance transportation
$200 per day
1 day(s) per calendar year
$250 per day
1 day(s) per calendar year
THE LIMITED BENEFIT INDEMNITY PLAN ALONE DOES NOT CONSTITUTE COMPREHENSIVE HEALTH INSURANCE COVERAGE (MAJOR MEDICAL
COVERAGE) AND DOES NOT SATISFY THE REQUIREMENT OF MINIMUM ESSENTIAL COVERAGE UNDER THE AFFORDABLE CARE ACT. HOWEVER,
THE PREVENTIVE CARE PLAN OFFERED AS PART OF PANABRIDGE ADVANTAGE DOES MEET THE REQUIREMENT UNDER THE AFFORDABLE CARE
ACT AS IT PROVIDES MINIMUM ESSENTIAL COVERAGE.
15
MEC MEDICAL INSURANCE INFO*
MEMBER SERVICES
Our member service representatives are
responsible for ensuring that customers receive
the best assistance with their questions and
concerns. Pan-American Life’s customer service
representatives interact with customers to
provide information in response to inquiries about
products and services. They communicate with
administrators and members through a variety of
means; by telephone, by e-mail, fax or mail.
We can assist members, companies and
providerswith:
•
Member Advocacy
•
ID Cards
•
Policy Information
•
Member Eligibility
•
Verification of Benefits
•
Prescription Benefits
•
PPO Network
Information
•
Account Management
•
Claims
•
And more!
Monday through Friday,
7:30 AM-5:00 PM, Central Time
1-800-999-5382
Full bilingual (English-Spanish) services
PPO PROVIDER NETWORK
USING IN-NETWORK PROVIDERS CAN
STRETCH YOUR BENEFITDOLLARS
Your plan includes access to the First Health Network,
which is more than a PPO Network, it is a full service
Managed Care Organization oering savings
opportunities on a national, directly contracted basis.
It provides access to more than 5,000 hospitals and
695,000 physicians and health care professionals
nationwide. First Health is committed to patient safety
at a high level by exercising care in the selection and
evaluation of providers for our network. Thorough
credentialing and re-credentialing processes minimize
unfavorable risks, which in turn, impacts clinical and
cost outcomes. In addition to the First Health Network,
our members also have access to a secondary, or
Wrap Network that provides them and their covered
dependents a broader access to Physicians and health
care professionals in urban, suburban, and rural areas.
MEMBER ADVOCACY
WHAT IS A MEMBER ADVOCATE?
A member advocate is an in-house
representative that works exclusively on behalf
of our members to reduce medical costs
and stressful billing situations. They can help
members find community programs, hospitals,
pharmaceutical companies, and provider
oces who have aordable treatment costs.
Also, they serve as a single point-of-contact
to help resolve on-going or challenging billing
issues. They’re even available to speak with
members individually, as well as their physicians
and medical facilities, so everyone has a full
understanding of how the benefits work and
can make the most informed choices regarding
planning medical treatment.
ADVOCATES CAN ASSIST WITH:
•
Medical bills & Prescription costs
•
Lab work & X-rays
•
CAT Scans / MRIs
•
Scheduling surgical procedures
•
Durable medical equipment
•
Diabetic supplies
•
Complicated claims and billing issues
THEY HELP LOWER COSTS BY:
•
Finding providers that oer sliding-scale
treatment pricing
•
Arranging payment plans for previously
incurred bills
•
Requesting discounted lump-sum payments to
settle balances
•
Locating community programs for specialized
services or frequently recurring expenses due
to chronic conditions
•
Contacting discount pharmacies
*Employees residing in Maine are oered an alternative MEC
plan. Please see page 35 for Maine-Only MEC coverage.
16
PAN-AMERICAN MEC BENEFITS*
GLOBAL REPATRIATION
HELPING TO PROVIDE PEACE OF
MIND DURING YOUR TIME OF NEED
The passing of a loved one is a dicult and
emotional experience. When it occurs during
travel, you or your loved ones may feel that help
is no longer within reach.
Global Repatriation is a worldwide benefit
designed to help your family when you or a
covered dependent suers a loss of life due
to a covered accident or illness while traveling
100 miles or more away from their permanent
residence. The benefit provides transportation
of a covered member’s remains to his/her
primary place of residence in the United States
and repatriation of foreign nationals to their
homecountries.
Benefit Includes:
•
Expenses for preparations; embalming
or cremation
•
Transport casket or air tray
•
Transportation of remains to place of residence
or place of burial
All services must be authorized and arranged by
AXA Assistance designated personnel and the
maximum benefit per person is $20,000 USD
per occurrence. No claims for reimbursement
will be accepted.
To Activate Assistance Call: 1-888-558-2703 /
1-312-356-5963
Global Repatriation benefits are independently
oered and administered by AXA Assistance
USA, Inc. www.axa-assistance.us.
Pan-American Life and AXA Assistance USA,
Inc. are not aliated. See policy for exclusions
andlimitations.
HEALTHIEST YOU
With HealthiestYou, you can connect to a doctor,
get treatment, and get prescriptions, 24 hours
a day, 7 days a week over the phone or via the
mobile app. Using HealthiestYou can SAVE YOU
TONS OF MONEY and no more sitting around in
waiting rooms. And best of all, it’s FREE!
24X7 UNLIMITED
DOCTORACCESS
Are you sick? Call
HealthiestYou first! Our
physician network can
diagnose, treat, and
prescribe with no consult
fees, anytime, anywhere.
Really!
PRESCRIPTION
SAVINGS
Need a prescription?
Our geo-based
Prescription search
engine can save you
up to 85% on your
prescription and
will often beat your
co-pay.
SHOP & PRICE
PROCEDURES
Do you need an MRI or
an Ultrasound? Our app
puts you in the driver’s
seat by providing a vehicle
to search and price
procedures in your direct
area. Happy shopping!
HEALTH
MANAGEMENT
CONTENT
Are you stressed? Let
HealthiestYou guide
you to improved
health and happiness
with relevant health
content delivered at
your time of need.
REGISTER AND ACCESS
YOUR ACCOUNT
member.healthiestyou.com
No internet? Call a doctor
1-855-894-9627
To learn how to
connect with a
doctor 24/7, shop
and price procedures,
prescription savings
and more. Watch our
video:
www.mypalic.com/
videohy
Don't forget to download the app
*Employees residing in Maine are oered an alternative MEC plan. Please see page 35 for Maine-Only MEC coverage.
17
PAN-AMERICAN MEC BENEFITS*
PRESCRIPTION DRUG INDEMNITY BENEFITS
Your prescription drug indemnity benefit will pay a maximum amount per day, per insured person,
with a maximum amount either per month or per calendar year (check your plan below). There are no
copayments, deductibles, or coinsurance.
PRESCRIPTION DRUG
INDEMNITY PAYS
PLAN 1 PLAN 2
Generic $10 per day $10 per day
Brand Discount Only $50 per day
CALENDAR YEAR MAXIMUM LIMIT
Generic 12 days per insured 12 days per insured
Brand - 12 days per insured
*Employees residing in Maine are oered an alternative MEC plan. Please see page 35 for Maine-Only MEC coverage.
18
MEDICAL WEEKLY RATES*
BCBST PLANS PAN-AM MEC PLANS
HRA PREMIER
CARE PLAN
– PPO
HIGH D – EPO
HSA
LOW D – PPO
HSA
PLAN 1 PLAN 2
NON-TOBACCO
Employee $49.22 $21.93 $40.33 $22.11 $28.79
Employee + Spouse $145.24 $58.38 $108.33 $42.48 $57.02
Employee +
Child(ren)
$133.82 $50.08 $98.76 $33.55 $44.63
Employee + Family $188.22 $79.85 $144.39 $56.84 $76.99
TOBACCO
Employee $92.99 $57.62 $106.07 $22.11 $28.79
Employee + Spouse $192.77 $94.07 $174.06 $42.48 $57.02
Employee +
Child(ren)
$181.16 $85.76 $164.49 $33.55 $44.63
Employee + Family $237.89 $115.53 $210.12 $56.84 $76.99
Ruby Tuesday is contributing up to a $500 HSA match per employee enrolled in the High-D and Low-D
HSA qualified plans. So, whether you are enrolled in individual coverage, employee + spouse coverage,
employee + child(ren) coverage, or family coverage, you get up to a $500 match per year deposited
tax free into the HSA divided into two deposits - one in the first half of the year and one in the second
half of the year.
PLEASE NOTE: The match amount counts toward your total IRS limit for the year.
The HRA will be administered by BlueCross BlueShield and will help oset the costs for qualified in-
network deductible expenses incurred by you or a covered family member. The money spent in your
HRA counts toward meeting your deductible; prescription drug copays are not reimbursable through
your HRA. Ruby Tuesday will fund $2,000 toward your HRA; if you have a covered family member on
your plan, Ruby Tuesday will fund $4,000 upon enrollment in the HRA Premier medical plan. Once your
HRA funds have been exhausted, you will be responsible for meeting the remainder of your calendar
year deductible. After the deductible has been satisfied, the medical plan will pay 80% of the allowable
charges, and you will be responsible for 20% up to the out-of-pocket maximum. After that, the plan will
pay 100% of covered expenses for the remainder of the calendar year. Your HRA balance will reset each
year on January 1.
The MEC Plans cover preventative services only, with limited hospital indemnity coverage. There is no
deductible or coinsurance and you are responsible for all non-preventative services.
*Employees residing in Maine are oered an alternative MEC plan. Please see page 35 for Maine-Only MEC coverage.
19
HEALTH SAVINGS ACCOUNT
When you are enrolled in the BCBST High-D or Low-D
plan, and meet the eligibility requirements, the IRS
allows you to open and contribute to an HSA Account.
WHAT IS A HEALTH SAVINGS
ACCOUNT (HSA)?
An HSA is a tax-sheltered bank account that you own
to pay for eligible health care expenses for you and/
or your eligible dependents for current or future
healthcare expenses. The Health Savings Account
(HSA) is yours to keep, even if you change jobs or
medical plans. There is no “use it or lose it” rule; your
balance carries over year to year.
Plus, you get extra tax advantages with an
HSA because:
•
Money you deposit into an HSA is exempt from federal
income taxes
•
Interest in your account grows tax free; and
•
You don’t pay income taxes on withdrawals used to pay
for eligible health expenses. (If you withdraw funds for
non-eligible expenses, taxes and
penalties apply).
•
You also have a choice of investment options which earn
competitive interest rates, so your unused funds grow
over time.
ARE YOU ELIGIBLE TO OPEN A HEALTH
SAVINGS ACCOUNT (HSA)?
Although everyone is able to enroll in the Qualified High Deductible Health Plan, not everyone is eligible to
open and contribute to an HSA. If you do not meet these requirements, you cannot open an HSA.
•
You must be enrolled in a Qualified High Deductible Health Plan (QHDHP)
•
You must not be covered by another non-QHDHP health plan, such as a spouse’s PPO plan.
•
You are not enrolled in Medicare.
•
You are not in the TRICARE or TRICARE for Life military benefits program.
•
You have not received Veterans Administration (VA) benefits within the past three months.
•
You are not claimed as a dependent on another person’s tax return.
•
You are not covered by a traditional health care flexible spending account (FSA). This includes your spouse’s FSA.
(Enrollment in a limited purpose health care FSA is allowed).
HOW DO I GET REIMBURSED FOR MY ELIGIBLE EXPENSES?
The easiest way to use your HSA dollars is by using your HSA Debit Card at the time you incur an eligible
expense. Or you can withdraw money from an ATM. But keep your receipts! You must be able to prove that
you were reimbursing yourself for an eligible expense if you are audited. If you use your HSA funds for non-
eligible expenses, you will be charged a 20% penalty tax (if under age 65) as well as federal income taxes.
HSA CONTRIBUTIONS
You are able to contribute to your Health
Savings Account on a pre-tax basis through
payroll deductions up to the IRS statutory
maximums. The IRS has established the
following maximum HSA contributions
for 2024:
•
$4,150 Individual or $8,300 Family
•
If you are age 55 and over, you may
contribute an extra $1,000 catch up
contribution.
•
Ruby Tuesday HSA Contribution: $500
Select the image below to see a brief video
for ways you can optimize your HSA.
20
DEPENDENT CARE FSA
WHAT IS A DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT
(DCFSA)?
A Dependent Care FSA lets members set aside money from their paycheck on a pretax basis to use
for eligible out-of-pocket expenses. Members can use this FSA to pay for eligible child and adult care
expenses like day care, before and after school care, nursery school, preschool and summer day camp.
HOW MUCH CAN I CONTRIBUTE TO MY DEPENDENT CARE FSA?
Generally, the maximum amount that may be contributed to the Dependent Care FSA is $5,000 and
determined on a calendar year basis.
Amounts contributed to the Dependent Care FSA are subject to the “use or lose” rule. This means any
unused contributions remaining at the end of the plan year are lost, unless the plan includes a grace
period (which provides up to 2.5 months to access unused contributions following the end of the plan
year). Review your plan documents to understand whether a grace period is available.
THE PAYFLEX
®
DEPENDENT CARE FSA
PAY THE PAYFLEX WAY
PayFlex makes it easy to pay for your eligible expenses.
•
Use the PayFlex Card®, your account debit card: When you use the PayFlex debit card (if oered),
your expense is automatically paid from your FSA.
•
Pay yourself back: Pay for eligible expenses with cash, check or your personal credit card. Then
submit a claim to pay yourself back. You can even have your claim payment deposited directly into
your checking or savings account.
•
Pay your provider: Use PayFlex’s online feature (if oered) to pay your provider directly from your
account.
Note: Some PayFlex cards are used for certain expenses. Check your plan details to confirm.
Quick tip: Save your itemized statements and detailed receipts of your expenses, as well as your
Explanation of Benefits from your insurance carrier.
21
PAYFLEX MOBILE
®
APP
PLAN, SAVE AND PAY ON THE GO
With our free PayFlex Mobile app, you can easily access your account information in the palm of your
hand.
SIMPLY “TAP” TO:
•
Check your account balance and view account
activity
•
View your account alerts
•
Access the Eligible Expense Scanner to verify if an
item is an eligible health care expense
•
Review a list of common eligible expense items
•
Pay your providers directly from your account
•
Take pictures of receipts and pay yourself back for
eligible expenses
WHAT’S NEW WITH THE PAYFLEX
MOBILE APP?
•
PayFlex’s Eligible Expense Scanner makes it easy
for you to scan an item barcode to determine if it’s
an eligible health care expense.
•
Enhanced security and complimentary fraud
protection.
HOW DO I GET THE PAYFLEX
MOBILE APP? AND IS THERE A FEE
TO USE IT?
•
You can download the app from your mobile
device’s app store.
•
The app is supported by the following devices:
•
iOS version 10 or
above on iPhone® 5S,
iPad Air®, iPad Mini® 2
or newer models
•
Android version 4.4
(Kitkat) or above on
phones or tablets
•
There’s no fee to download the app. Anyone with a
PayFlex account can use it for free.
CAN I SUBMIT A CLAIM USING THE
APP?
Yes, you can submit a claim through the app if you
want to reimburse yourself for an expense.
•
After you log in, select Manage Funds to get
started.
•
When sending documents with your claim, simply
take a picture and upload it through the app.
HOW DO I ACCESS THE ELIGIBLE
EXPENSE SCANNER?
After you log in to the app, you can find it on the
home page or tap HELP to access the Eligible
Expense Scanner.
HOW DO I GET STARTED WITH THE
APP?
It’s easy. Just use the same username and
password you use for the PayFlex member
website. If you haven’t set up your online account
with PayFlex, go to payflex.com to get started.
Note: Standard text messaging rates and other rates from your wireless carrier may apply when using the PayFlex Mobile® app.
PayFlex Systems USA, Inc. This material is for informational purposes only and is not an oer of coverage. It contains only a
partial, general description of plan benefits or programs and does not constitute a contract. It does not contain legal or tax
advice. You should contact your legal counsel if you have any questions or if you need additional information. In case of a conflict
between your plan documents and the information in this material, the plan documents will govern. Eligible expenses may vary
from employer to employer. Please refer to your employer’s Summary Plan Description (“SPD”) for more information about your
covered benefits. Information is believed to be accurate as of the production date; however, it is subject to change. PayFlex
cannot and shall not provide any payment or service in violation of any United States (U.S.) economic or trade sanctions. For
more information about PayFlex, go to PayFlex.com. PayFlex Mobile® is a registered trademark of PayFlex Systems USA, Inc.
Apple, the Apple logo, iPad and iPhone are trademarks of Apple Inc., registered in the U.S. and other countries. Android is a
trademark of Google LLC.
22
DENTAL INSURANCE
Brushing your teeth and flossing are great, but don’t forget to visit the dentist too! Ruby Tuesday oers
aordable plan options for routine care and beyond. Coverage is available from BlueCross BlueShield of
Tennessee, Inc.
Please Note: It is recommended that when a course of treatment is expected to cost $300 or more, and
is of a non-emergency nature, your dentist should submit a treatment plan before he/she begins. This
enables you to see what your out-of-pocket expenses will be so you are not surprised and can budget
accordingly. There is also a possibility that suggested procedures may be denied, and alternative
procedures approved based upon X-rays and supporting documentation.
Please refer to the summary plan description for complete plan details. Please note that you will receive
a dental ID card.
BLUECROSS BLUESHIELD OF TENNESSEE, INC. DENTAL
IN-NETWORK OUT-OF-NETWORK
CALENDAR YEAR PLAN MAXIMUM
Per Individual
$2,000 per individual
(Basic and MajorServices combined)
ANNUAL DEDUCTIBLE
Individual $0 $0
Family $0 $0
Waived for Preventive Care? Yes Yes
PREVENTIVE CARE
Oral exams, X-rays & diagnostic, teeth cleanings (1
every 6 months), fluoride treatment, topical sealant,
emergency treatment
0% 0%
BASIC SERVICES
Minor Restorative Services, Fillings, Space Maintainers,
Oral Surgery, Extractions, Periodontics, Endodontics,
Stainless Steel Crowns, Repairs to Crowns and
Bridgework, Occlusion Adjustment, Local Anesthesia
50% 50%
MAJOR PROCEDURES
Porcelain Crowns, Fixed and Removable Bridgework,
Full and Partial Dentures
50% 50%
ORTHODONTIA
Adults
50% up to a lifetime maximum benefitof $2,000 per
individual; deductible waived; No waiting period
Children (up to 19th birthday)
DENTAL PREMIUM RATES
PER WEEK
Employee $6.57
Employee + Spouse $12.50
Employee + Child(ren) $11.41
Employee + Family $15.99
23
VISION INSURANCE
BlueCross BlueShield of Tennessee, Inc. has a large network of Eye Care Providers. By seeing a
preferred provider you have the benefit of a low copayment for a vision exam and materials. You may
also go to out of network providers, but you will need to pay for services and then submit a claim form
for the reimbursed allowances.
You will not receive a Vision ID card. You can give your provider your ID Number or SSN and they will
be able to locate your policy and benefits.
BLUECROSS BLUESHIELD OF TENNESSEE, INC. VISION
BENEFIT COVERAGE BASE PLAN PREMIER PLAN
IN-NETWORK BENEFITS IN-NETWORK BENEFITS
YOU PAY
Exam $10 copay $10 copay
Single Vision Lenses $25 copay $25 copay
Bifocals Lenses $25 copay $25 copay
Trifocals Lenses $25 copay $25 copay
Frames – Retail Equivalent $0 copayment up to $150 allowance up to $200 allowance
Contacts
• Necessary/Prescribed
• Elective
100%
$0 copayment up to $125 allowance
100%
$0 copayment up to $175 allowance
BENEFIT FREQUENCY
Exams Once every 12 Months Once every 12 Months
Lenses Once every 12 Months Once every 12 Months
Frames Once every 24 Months Once every 12 Months
Contacts (Elective) Once every 12 Months Once every 12 Months
VISION PREMIUM RATES
PER WEEK BASE PLAN PREMIER PLAN
Employee $1.09 $1.87
Employee + Spouse $2.07 $3.56
Employee + Child(ren) $2.18 $3.75
Employee + Family $3.20 $5.51
24
LINCOLN EMPLOYEE ASSISTANCE
PROGRAM
THE RESOURCES YOU NEED TO MEET LIFE’S CHALLENGES
EmployeeConnect
SM
oers professional, confidential services to help you and your loved ones improve
your quality of life.
IN-PERSON GUIDANCE UNLIMITED 24/7 ASSISTANCE ONLINE RESOURCES
Some matters are best resolved
by meeting with a professional in
person. With EmployeeConnect, you
and your family get:
• In-person help for short-term
issues (up to five sessions with a
counselor per person, per issue,
per year)
You and your family can access
the following services anytime —
online, on the mobile app, or with a
toll-free call:
• Information and referrals on
family matters, such as child and
elder care, pet care, vacation
planning, moving, car buying,
college planning and more
EmployeeConnect oers a wide
range of information and resources
you can access on your own.
Expert advice and support tools
are just a click away when you
visit GuidanceResources.com or
download the GuidanceNow
SM
mobile app. You’ll find:
• Articles and tutorials
• Videos
EMPLOYEECONNECT
SM
EMPLOYEE ASSISTANCE PROGRAM SERVICES
Confidential help 24 hours a day, seven days a
week for employees and their family members.
Get help with:
•
Family
•
Parenting
•
Addictions
•
Depression
•
Relationships
•
Stress
EMPLOYEECONNECT
SM
EMPLOYEE ASSISTANCE PROGRAM SERVICES
To learn more:
•
Visit GuidanceResources.com
•
(username: LFGNY | password: LFGNY1)
•
Download the GuidanceNow
SM
mobile app
•
Call 833-475-0980
EMPLOYEECONNECT
SM
COUNSELORS ARE EXPERIENCED AND
CREDENTIALED.
When you call the toll-free line, you’ll talk to an experienced professional who will provide counseling,
work-life advice, and referrals. All counselors hold master’s degrees, with broad-based clinical skills and
at least three years of experience in counseling on a variety of issues. For face-to-face sessions, you’ll
meet with a credentialed, state-licensed counselor.
You’ll receive customized support for each work-life service you use.
25
LIFE AND AD&D
BASIC LIFE AND ACCIDENTAL
DEATH & DISMEMBERMENT
Ruby Tuesday provides you with Basic Life and AD&D
coverage at no cost to you through Lincoln! For newly
eligible employees, coverage is eective on the 1st of
the month following the date of hire. Basic Life does
not apply to full-time hourly employees.
•
Regional Director of Operations, receive two times
your covered annual salary up to $250,000. Managers,
Managers in Training, and Support Center Team Members receive $25,000 for both Basic Life and AD&D.
•
No medical underwriting is required. You are automatically covered for this benefit but be sure to designate a
beneficiary during the enrollment process.
IMPORTANT REMINDER!
You MUST designate a beneficiary for your
Life and AD&D insurance when you become
eligible for coverage or upon enrollment.
This will ensure your assets are distributed
according to your wishes.
DISABILITY INSURANCE
SHORT TERM DISABILITY (STD)
In the event you are unable to work as a result of an illness or injury, Ruby Tuesday provides disability
insurance through Lincoln. The plans oer income protection and may replace a portion of your
earnings while you are unable to work. If your disability extends beyond 26 weeks, you may be eligible
to receive Long Term Disability benefits. For newly eligible employees, coverage is eective on the 1st
of the month following the date of hire.
SHORT TERM DISABILITY
BENEFIT COVERAGES
MANAGERS, REGIONAL DIRECTOR OF OPERATIONS, SUPPORT
CENTER, FULL-TIME HOURLY RESTAURANT TEAM MEMBERS
Elimination Period Covered Injury / Illness on the first day | 0 days accident / 0 days sickness
Benefit Percentage 60% of your weekly salary
Maximum Weekly Benefit $2,000
Maximum Period of
Payment
26 weeks
Employees who work in NY, NJ, CA, RI or HI are not eligible to purchase this coverage. NY employees are automatically covered
by Ruby Tuesday for statutory benefits that cover 50% of your salary up to a maximum benefit amount of $170 per week.
26
VOLUNTARY LIFE AND AD&D
VOLUNTARY LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT
You may purchase additional Life and AD&D coverage for yourself and your dependents. When
unexpected events occur, our Accidental Death & Personal Loss plans can help provide much-needed
financial support and stability. Covered events include accidental death, paralysis, third-degree burns,
comas, and loss of speech, hearing, sight or limbs. We expedite claims processing.
For newly eligible employees, coverage is eective on the 1st of the month following the date of hire.
If you do not enroll when you are first eligible to do so, you and your spouse will be subject to
providing evidence of insurability (medical underwriting) for any amount of coverage if you decide
toenroll at a later date.
VOLUNTARY LIFE AND AD&D
YOU
MANAGERS, REGIONAL DIRECTOR OF OPERATIONS,
SUPPORT CENTER TEAM MEMBERS
Benefit Maximum
Life: up to 5x your wage, up to $500,000 ($250,000 for Managers and Managers in Training)
AD&D: up to 5x your wage, up to $500,000 ($250,000 for Managers and Managers in
Training)
Guaranteed Issue 3x annual earnings or $100,000
YOUR SPOUSE
Benefit Maximum
Life: Increments of $10,000, up to a maximum of $250,000. (Not to exceed 100% of the
employee’s Supplemental Life benefit)
AD&D: Amount equal to 50% of employee's voluntary AD&D amount, not to exceed
$250,000 (with or without children)
Guaranteed Issue $50,000
YOUR CHILD
Benefit Maximum
Life: $2,500 increments, up to $10,000
AD&D: Amount equal to 15% of employee's voluntary AD&D, up to $75,000
Guaranteed Issue $10,000
Plan options include:
•
Childcare benefit — to help pay for state-licensed childcare centers
•
Educational benefit — to help ensure higher education for dependent children & training for spouses or
domestic partners
•
Passenger restraint and airbag benefit — for proper use of restraint devices during an accident
•
Repatriation of remains benefit — if a covered employee or dependent dies while at least 200 miles from home
27
VOLUNTARY LONG TERM DISABILITY (LTD)
You may purchase long-term disability insurance, which provides you with monthly income protection
for covered disabilities that last longer than 26 weeks.
LONG TERM DISABILITY
BENEFIT COVERAGES
MANAGERS, REGIONAL
DIRECTOR OF OPERATIONS,
SUPPORT CENTER TEAM
MEMBERS
FULL-TIME HOURLY RESTAURANT
TEAM MEMBERS
Elimination Period
After 180 days of disability or the end of
short-term disability benefits, whichever
occurs later
After 180 days of disability or the end of
short-term disability benefits, whichever
occurs later
Benefit Percentage 60% of your weekly salary 60% of your weekly salary
Maximum Monthly Benefit $10,000 $900
Maximum Period of
Payment
Social Security normal retirement age Social Security normal retirement age
LTD benefits received are reduced by State Disability Income (SDI) for employees residing in states with a State Disability
Program (CA, NY, NJ, HI, and RI), Workers Compensation and Social Security.
VOLUNTARY DISABILITY
EVIDENCE OF INSURABILITY
Note: If enrolled, you are not covered until EOI is
approved (if it was required).
WHAT IS EOI AND WHEN IS IT
NEEDED?
EOI is the information we use to verify your good health
when you’re purchasing life, disability, or critical illness
insurance. We require EOI if you are:
• Buying an insurance amount higher than the
guaranteed amount for your plan
• Already enrolled and want to increase coverage
GET STARTED NOW
1. Log in to my MyLincolnPortal.com.
First time user? Register using : LF1071RUB
2. Click “Complete Evidence of Insurability.”
3. Answer the questions about you and other
applicants. You’ll be asked:
• General applicant information, such as date of birth,
height, and weight
• Qualifying questions, including if you or other
applicants have been diagnosed with a disease or
are prescribed medications for a condition
• Medical questions—if you or other applicants have a
condition, we may need to know a little more about
it, such as the name, diagnosis date, andtreatments
4. Review your responses, then electronically sign and
submit your application.
5. Save your confirmation report.
WHAT HAPPENS NEXT?
In some cases, you may be auto-
approved for coverage. If not,
we’ll review your application and
contact you if more information
is required. In all cases, we’ll
notify you of your application
outcome.
QUESTIONS?
For more information,
contact your human
resources department.
SUBMITTING EOI MADE EASY
MINIMAL QUESTIONS
The online questionnaire adjusts to your responses, so you only
answer questions that are relevant to you.
GUIDED SUPPORT
Quick tips and search as-you-type features help you provide quick
and appropriate responses.
INSTANT CONFIRMATION
You’ll receive email acknowledgment that we’ve received your
application. In some cases, you may be automatically approved.
28
ATTAINED AGE*^
MONTHLY PREMIUM RATE PER S1.000 OF DEPENDENT SPOUSE OR
LIFE PARTNER CRITICAL ILLNESS INSURANCE
17-24 $0.515
25-29 $0.653
30-34 $0.785
35-39 $0. 964
40-44 $1.294
45-49 $1.673
50-54 $2.263
55-59 $3.026
60-64 $4.187
65-69 $5.665
70+ $5.752
* The Insured Dependent Spouse's or Life Partner's age will determine the applicable Dependent Spouse or Life Partner
Premium rate
^ Premium will be calculated as of the Insured Dependent Spouse's or Life Partner's age on each Policy Anniversary.
ATTAINED AGE*^
MONTHLY PREMIUM RATE PER $1,000 OF INSURED'S
CRITICAL ILLNESS INSURANCE
17-24 $0.515
25-29 $0.653
30-34 $0.785
35-39 $0.964
40-44 $1.294
45-49 $1.673
50-54 $2.263
55-59 $3.026
60-64 $4.187
65-69 $5.665
70+ $5.752
* The Insured's age will determine Insured's Premium rate
^ Premium will be calculated as of the Insured's age on each Policy Anniversary.
Monthly Premium rate per $1,000 of Dependent Child(ren) Critical Illness Insurance: $0.685
The Lincoln Critical Illness plan is designed to help employees and their families with the out-of-pocket
costs associated with a critical illness. Critical illnesses include Heart Attack, Stroke, Major Organ
Transplant, End-Stage Renal Failure, Cancer, and additional conditions.
•
Employees select an Initial Benefit of $5,000 increments up to $30,000. A Spouse/Domestic Partner can
select an initial benefit up to $2,500 increments up to $15,000 (not to exceed 50% of employee’s benefit),
and children’s elections are $2,500 increments up to $7,500.
•
No medical questions as long as the employee is actively at work and has medical coverage.
•
Benefits are paid directly to the insured on a post-tax basis.
•
This plan is portable, so you may continue coverage if you leave the company for any reason.
VOLUNTARY CRITICAL ILLNESS
29
The Lincoln Accident Insurance plan provides employees with a choice of two comprehensive plans
(Option 1 or Option 2) which provide payments for covered accidents.
•
With over 150 covered events, including hospitalization resulting from an accident as well as accidental
death or dismemberment, the Lincoln Accident Insurance plan will pay for covered accidents in addition to
any other insurance payments you may receive.
•
Coverage is Guaranteed Issue, no medical questions are asked.
•
Spouse and Dependent Child(ren) coverage is also available. This plan is portable, so you may continue
coverage if you leave the company for any reason.
ACCIDENTAL INJURY BENEFITS PLAN 1 - ACCIDENT LOW PLAN PLAN 2 - ACCIDENT HIGH PLAN
TYPE OF INJURY BENEFIT AMOUNT BENEFIT AMOUNT
NON-SURGICAL SURGICAL NON-SURGICAL SURGICAL
FRACTURES
Ankle $450 $900 $575 $1,150
Arm (shoulder to elbow) $875 $1,750 $1,125 $2,250
Arm (elbow to wrist) $450 $900 $575 $1,150
Collarbone $525 $1,050 $675 $1,350
Elbow $450 $900 $575 $1,150
Finger $100 $200 $125 $250
Foot (except toes) $450 $900 $575 $1,150
Hand (except fingers) $450 $900 $575 $1,150
Leg (hip to knee) $2,625 $5,250 $3,375 $6,750
Leg (knee to ankle) $1,750 $3,500 $2,250 $4,500
Nose $875 $1,750 $1,125 $2,250
Rib $450 $900 $575 $1,150
Toe $100 $200 $125 $250
Wrist $450 $900 $575 $1,150
Chip Fracture 25% of the amount payable for full Fracture
DISLOCATIONS
Ankle $875 $1,750 $1,125 $2,250
Elbow $450 $900 $575 $1,150
Finger $100 $200 $125 $250
Foot (except toes) $875 $1,750 $1,125 $2,250
Hand (except fingers) $450 $900 $575 $1,150
Toe $100 $200 $125 $250
Wrist $450 $900 $575 $1,150
Partial Dislocation 25% of benefit payable for Dislocation
SPECIFIC INJURY BENEFITS
Concussion $150 $200
Eye Injury
Surgical Repair
Removal of foreign body
$300
$150
$400
$200
Lacerations No Sutures Required $35 $50
Lacerations
Sutures Required
(Total Length of all Sutured Lacerations)
5cm or less $75
5.1-15.5cm $200
15.6cm or more $400
5cm or less $100
5.1-15.5cm $300
15.6cm or more $600
LINCOLN ACCIDENT INSURANCE PLAN RATES
PER WEEK OPTION 1 OPTION 2
Employee $2.14 $2.82
Employee + Spouse $3.60 $4.69
Employee + Child(ren) $4.03 $5.20
Employee + Family $5.45 $7.03
VOLUNTARY ACCIDENT
COVERAGE
30
VOLUNTARY LEGAL PLAN
MetLife's Legal Plans, Inc. is a voluntary group legal plan which provides fully covered legal advice
and representation for most personal legal matters (employment and business-related matters are
excluded from coverage). Once enrolled, employees have access to an attorney, as if on retainer,
through Hyatt’s nationwide network of 12,000 pre-qualified attorneys. Employees may contact a Plan
Attorney for representation for a wide range of legal services, in addition to telephone advice and
oce consultations on an unlimited number of personal legal matters.
FIND A PLAN ATTORNEY
Visit: www.legalplans.com
Call: 800-821-6400
Legal Services Policy Number: 990-4330
WEEKLY RATE
METLIFE LEGAL WEEKLY RATE
Employee $4.85
Includes coverage for eligible dependents
LEGAL SERVICES*
Advice and
Consultation
Oce Consultations
Will and Estate
Planning
Trusts
Telephone Advice Living Wills
Consumer
Protection Matters
Small Claims Assistance
Real Estate Matters
Eviction and Tenant Problems
(Tenant Only)
Personal Property Protection
Home Equity Loans
(Primary Residence)
Review personal
legaldocuments
Property Tax Assessment
Trac Infractions Restoration of Driving Privileges Juvenile Matters Juvenile Court Defense
Financial Matters
Debt Collection Defense
Family Law
Name Change
Identity Management Services Prenuptial Agreement
Identity Theft Defense Protection from Domestic Violence
Personal Bankruptcy Adoption and Legitimization
Tax Audits
Divorce, Dissolution, Annulment
(up to 20 hrs)
Financial Education Guardianship or Conservatorship
Defense of Civil
Lawsuits
Administrative Hearing
Representation
Document
Preparation
Adavits
Civil Litigation Demand Letters
Incompetency Defense Mortgages
*With MetLife Plan Attorney; exclusions and Limitations apply
31
VOLUNTARY PET INSURANCE
MY PET PROTECTION
®
My Pet Protection pet insurance from Nationwide
is a reimbursement indemnity plan.That means we
reimburse members for a portion of eligible veterinary
expenses relatedto accidents, injuries and illnesses.*
HOW TO ENROLL:
Call 877-738-7874 to speak with a Nationwide
representative and mention you are an employee of Ruby
Tuesday or visit benefits.petinsurance.com/rubytuesday.
Note: You can enroll or drop anytime.
MY PET PROTECTION®
MY PET PROTECTION®
WELLNESS500
Annual deductible $250 $250
Reimbursement Up to 70% Up to 70%
Maximum annual benefit $7,500 $7,500
Pre-existing conditions Not included Not included
Accidents and illnesses Included Included
Hereditary and congenital Included Included
Cancer Included Included
Dental disease Included Included
Hospitalization or treatment Included Included
Behavioral treatments Included Included
Rx therapeutic supplements Included Included
Dental cleanings Not included Included up to $500
Wellness exams Not included Included up to $500
Vaccinations Not included Included up to $500
Flea prevention Not included Included up to $500
Spay/neuter Not included Included up to $500
24/7 vethelpline® ($110 value) Included Included
PetRxExpressSM Included Included
Advertising and reward Included Included
Emergency boarding Included Included
Loss due to theft Included Included
Mortality benefit Included Included
MULTI-PET DISCOUNT
2-3 Pets 5%
4+ Pets 10%
Avian and exotic pet coverage
Nationwide is the only pet insurer in the
United States to oer coverage for birds
and exotic pets like reptiles and small
mammals. Avian and exotic pet plans are
available only by phone. Benefits include:
•
Veterinary exams, including specialty and
emergency visits
•
Hospitalization and surgeries
*Premium calculation, rating variables and/or rates
are subject to change based on approval by the
Department of Insurance in each individual state.
Rates are guaranteed for one year from the policy
eective date based on information provided at the
time of enrollment.
Premium is based on:
•
Species of pet
•
Employee
ZIP code
•
Age of pet
•
Breed of pet
•
Reimbursement
level selected:
50% or 70%
32
CHUBB TERM LIFE
This coverage pays a benefit up to $250,000 that
can be used as your beneficiary sees fit. It can
help cover funeral expenses, medical expenses,
debts and more. This is electable in increments
of 1 time to 5 times your basic annual earnings
up to $100,000 with no medical questions.
Note: Coverage may require EOI.
COMMUTER BENEFIT
The Commuter Benefit Plan is available to New
York, New Jersey, & Philadelphia employees only
•
This benefit makes it easy to order transit and
parking passes, vouchers, or a Commuter Check
online through PayFlexDirect.com.
ADDITIONAL VOLUNTARY
BENEFITS
Get identity protection for real life.
Sign up during open enrollment.
Questions? 1-800-789-2720
ALLSTATE IDENTITY PROTECTION PRO
$2.30 per person / weekly
$4.14 per family / weekly
¹2021 Identity Fraud Study, Javelin Strategy & Research
HOSPITAL INDEMNITY
There are two options for voluntary Hospital Indemnity plans oered through Lincoln Financial.
LINCOLN HOSPITAL INDEMNITY WEEKLY RATES
PER WEEK OPTION 1 OPTION 2
Employee $3.19 $5.47
Employee + Spouse $7.07 $12.12
Employee + Child(ren) $6.02 $10.33
Employee + Family $9.70 $16.62
PLAN BENEFITS
TYPE OF BENEFIT OPTION 1 - LOW PLAN OPTION 2 - HIGH PLAN
BENEFIT AMOUNT
Hospital Admission (1 per year) $850 per day $1,500 per day
Hospital Confinement (up to 3 per year) $300 per day $500 per day
ALLSTATE IDENTITY THEFT
PROTECTION
Every 2 seconds there is a new victim of
identity fraud and 1 in 4 people have already
experienced identity theft. Identity crime
can happen to anyone — 1 in 6 Americans
have been impacted by an identity crime¹ no
matter how careful you are. That’s why your
company oers Allstate Identity Protection
Pro+ as a benefit. Allstate Identity Protection
is proud to have a broad, inclusive definition
of “family” that covers everyone under your
roof (or under your wallet) — no matter their
age. Get comprehensive identity monitoring
and fraud resolution designed to help you
protect yourself and your family against
today’s digital threats.
For over 90 years, Allstate has been
protecting what matters most. Prepare for
what’s next with:
•
Identity, financial account, and
creditmonitoring
•
24/7 alerts and fraud recovery
•
Up to $1 million in identity theft
expensereimbursement
33
401(k) RETIREMENT PROGRAM
Whether you’re just starting out in your career, or you’ve been in the workforce for years, it’s always a
good time to plan for retirement. Contributing to a 401(k) account now can help keep you financially
secure later in life. The Ruby Tuesday 401(k) plan provides you with the tools and flexibility you need
to prepare.
WHAT IS A 401(k)?
This employer-sponsored retirement account can help build and create choices for your future self by
saving money — tax free — from your paycheck. Due to the value of compounding interest, the sooner
you participate in a 401(k), the better. Eligible employees can invest for retirement while receiving certain
tax advantages. Administrative and record-keeping services for this plan are provided by Principal. You
may start making pre-tax contributions into the plan after six months of service.
The plan oers a convenient, tax-deferred way to save.
•
Who Can Join?
Any employee age 21 or older who has worked for Ruby Tuesday 6 months and makes less than $150,000
per year.
•
How Much Can You Contribute?
On a pre-tax basis: 1% to 50% of your pay up to $23,000 in 2024. This limit is adjusted annually each year by
the IRS. You can also contribute on after-tax basis up to 10% of your gross pay or Roth after-tax basis.
•
Does Ruby Tuesday Contribute?
50% match of contributions, up to 6% of salary. Total match, up to 3% of salary.
•
How Can You Join?
Call Principal at 1-800-547-7754 or via internet at www.principal.com.
PRE-TAX VS. ROTH 401(k)
What’s the dierence? If you contribute to your 401(k) pre-tax, your contributions will be taken out
before taxes each pay period. However, you’ll have to pay taxes on the funds when you withdraw them
during retirement. If you choose the available Roth 401(k), contributions will be deducted from your
paycheck after taxes — so you won’t pay taxes when you withdraw during retirement. Once you retire,
you might be in a higher tax bracket, so contributing after taxes now could save you money in the
long run.
34
HELPFUL TERMINOLOGY
•
Brand preferred drugs – A drug with a patent and
trademark name that is considered “preferred”
because it is appropriate to use for medical
purposes and is usually less expensive than other
brand-name options.
•
Brand non-preferred drugs – A drug with a
patent and trademark name. This type of drug is
“not preferred” and is usually more expensive than
alternative generic and brand preferred drugs
•
Calendar Year Maximum – The maximum benefit
amount paid each year for each family member
enrolled in the dental plan.
•
Coinsurance – The sharing of cost between you
and the plan. For example, 80 percent coinsurance
means the plan covers 80 percent of the cost
of service after a deductible is met. You will be
responsible for the remaining 20 percent of the cost.
•
Copay – A fixed amount (for example $15) you pay
for a covered health care service, usually when you
receive the service. The amount can vary by the
type of covered health care service.
•
Deductible – The amount you must pay for covered
services before your health plan begins to pay.
•
Elimination Period – The time between the
beginning of an injury or illness and receiving
benefit payments from the insurer.
•
Health Spending Accounts (HSA) – HSAs allow you
to pay for eligible health care and dependent care
expenses using tax-free dollars. The money in the
account stays in the account and can build year
over year if it is not spent. This means you do not
need to spend the money in the account before the
end of the plan year.
•
Generic drugs – A drug that oers equivalent uses,
doses, strength, quality, and performance as a
brand-name drug, but is not trademarked.
•
In-network – A designated list of health care
providers (doctors, dentists, etc.) with whom the
health insurance provider has negotiated special
rates. Using in-network providers lowers the cost of
services for you and the company.
•
Inpatient – Services provided to an individual
during an overnight hospital stay.
•
Mail Order Pharmacy – Mail order pharmacies
generally provide a 90-day supply of a prescription
medication for the same cost as a 60-day supply at
a retail pharmacy. Plus, mail order pharmacies oer
the convenience of shipping directly to yourdoor.
•
Out-of-network – Health care providers that are not
in the plan’s network and who have not negotiated
discounted rates. The cost of services provided by
out-of-network providers is much higher for you
and the company. Additional deductibles and higher
coinsurance will apply.
•
Out-of-pocket maximum – The maximum amount
you and your family must pay for eligible expenses
each plan year. Once your expenses reach the
out-of-pocket maximum, the plan pays benefits
at 100% of eligible expenses for the remainder of
the year. Your annual deductible is included in your
out-of-pocket maximum.
•
Outpatient – Services provided to an individual at a
hospital facility without an overnight hospital stay.
•
Primary Care Provider (PCP) – A doctor
(generally a family practitioner, internist, or
pediatrician) who provides ongoing medical care.
A primary care physician treats a wide variety of
health-relatedconditions.
•
Reasonable & Customary Charges (R&C) –
Prevailing market rates for services provided by
health care professionals within a certain area for
certain procedures. Reasonable and Customary
rates may apply to out-of-network charges.
•
Specialist – A provider who has specialized
training in a particular branch of medicine (e.g., a
surgeon, cardiologist, or neurologist).
•
Specialty drugs – A drug that requires special
handling, administration, or monitoring. Most can
only be filled by a specialty pharmacy and have
additional required approvals.
35
MAINE-ONLY MEC
MEDICAL PLAN
This plan is available to residents of Maine only. Oered through Pan-American, this plan covers
preventative services only.
Preventive care coverage now covers 100% of eligible preventive service costs when performed in-
network. That means that you pay nothing out of pocket for access to a variety of medical screenings,
exams, and immunizations which may help reduce your risk of developing health conditions in the
future and avoid expensive treatment down the road.
Preventive care includes screenings, tests, medicines and counseling performed or prescribed by your
doctor or other health care provider to test for conditions which may develop even when you don’t
have signs or symptoms of an injury or illness.
MAINE-ONLY MEC MEDICAL PLAN RATES
PER WEEK
Employee $6.10
Employee + Spouse $8.55
Employee + Child(ren) $7.76
Employee + Family $10.92
PPO PROVIDER NETWORK
Your plan includes access to the First
Health Network.
To locate in-network Physicians or Hospitals
call 1-888-561-5759 or visit
www.providerlocator.com/palicfh to
search online
MEMBER SERVICES
We can assist members, companies and
providers with:
•
Member Advocacy
•
ID Cards
•
Policy Information
•
Member Eligibility
•
Verification of
Benefits
•
PPO Network
Information
•
Account Management
•
Claims
•
And more!
Monday through Friday, 7:30 AM – 5:00 PM,
Central Time call 1-800-999-5382.
AFTER YOU ENROLL
Once you enroll in the plan, you will receive
your ID Card(s) by mail. The information in your
card will help you register to our online member
portal at mypalic.com, where you will have
24-hour access to:
•
Review claims
•
Access plan
documents
•
See your benefits
•
Find in-network
providers
•
Print ID cards
•
Download forms
•
Frequently Asked
Questions
•
And much more
EXAMPLE OF COVERED
PREVENTIVE SERVICES FOR
ADULTS:
Screenings for:
•
Blood pressure
•
Cholesterol
(for adults of certain
ages or athigher risk)
•
Colorectal cancer
(for adults over 50)
•
Depression
•
Type 2 diabetes
(for adults with high
bloodpressure)
36
EXAMPLE OF COVERED
PREVENTIVE SERVICES FOR
ADULTS: (CONTINUED)
Immunizations:
•
Hepatitis A
•
Hepatitis B
•
Human
papillomavirus (HPV)
•
Influenza (Flu)
•
Measles, mumps,
rubella (MMR)
•
Meningococcal
(meningitis)
•
Pneumococcal
(pneumonia)
•
Varicella
(chicken pox)
Counseling for:
•
Alcohol misuse
•
Obesity
•
Sexually transmitted infection (STI) prevention
(for adults at higher risk)
•
Tobacco use (including programs to help you
stop using tobacco)
ADDITIONAL COVERED
PREVENTIVE SERVICES
FOR WOMEN
•
Contraception (FDA approved and ACA required
contraceptive methods, sterilization procedures,
and patient education and counseling)
•
Well-woman visits (to obtain recommended
preventive services for women under 65)
Screenings for:
•
Breast cancer (mammography every 1 to 2 years
for women over 40)
•
Cervical cancer (for sexually active women)
•
Chlamydia infection (for younger women and
other women at higher risk)
•
Domestic and interpersonal violence
•
Gestational diabetes (for those at high risk)
•
Gonorrhea (for all women at higher risk)
•
Human Immunodeficiency Virus (HIV)
(for sexually active women)
Additional services for pregnant women:
•
Anemia screenings
•
Bacteriuria urinary tract or other infection
screenings
•
Breast feeding interventions to support and
promote breast feeding after delivery
•
Expanded counseling on tobacco use
•
Gestational diabetes (screening for women
24 to 28 weeks pregnant)
•
Hepatitis B counseling (at the first prenatal visit)
COVERED PREVENTIVE
SERVICES FOR CHILDREN
Screenings and assessments for:
•
Alcohol and drug use (for adolescents)
•
Autism (for children at 18 and 24 months)
•
Behavioral issues
•
Blood pressure (screening for children)
•
Cervical dysplasia (for sexually active females)
•
Congenital hypothyroidism (for newborns)
•
Depression (screening for adolescents)
•
Developmental (screening for children under age
3, and surveillance throughout childhood)
•
Dyslipidemia (screening for children at higher risk
of lipid disorders)
•
Hearing (for all newborns)
•
Height, weight and body mass index
measurements
•
Hematocrit or hemoglobin
•
Hemoglobinopathies or sickle cell (for newborns)
•
HIV (for adolescents at higher risk)
•
Lead (for children at risk of exposure)
•
Medical history
•
Obesity
•
Oral health risk assessment (for young children)
•
Phenylketonuria (PKU) (newborns)
•
Tuberculin testing (for children at higher risk
oftuberculosis)
•
Vision (screening as part of physical exam,
notseparate eye exam)
Immunizations:
From birth to age 18. Doses, recommended ages,
and recommended populations vary.
•
Diphtheria, pertussis, tetanus (DPT)
•
Hæmophilus influenzæ type b
•
Hepatitis A
•
Hepatitis B
•
Human papillomavirus (HPV)
•
Inactivated poliovirus
•
Influenza (Flu)
•
Measles, mumps, rubella (MMR)
•
Meningococcal (meningitis)
•
Pneumococcal (pneumonia)
•
Rotavirus
•
Varicella (chicken pox)
37
PRESCRIPTION DRUG COVERAGE
The following chart shows categories of pharmaceuticals available to you at no cost. As lists may change,
please note that in order to determine which specific drugs or brands within each of the below categories
are covered under your prescription benefits, you will need to contact RxEDO at 1-888-879-7336 or go
online to rxedo.com for more information.
ITEM AVAILABILITY COVERAGE
Aspirin
Adult men and women
45 years or more
Generic, OTC
Folic Acid supplements
Adult women
Up to 55 years
Generic, OTC
Fluoridated drugs 6 months – 5 years Brand, generic
Tobacco Cessation Adult men and women
• Generic or OTC only on nicotine
replacement products
• Limit to Generic Zyban
ADDITIONAL COVERED PREVENTIVE SERVICES FOR WOMEN
Oral Contraceptives
Adult women
Generic, single source brands
Emergency contraception Generic, OTC, single source brands
Injectable contraceptives Generic, single source brands
Transdermal patch Generic, single source brands
Diaphragm and cervical cap Generic, single source brands
SAVE ON DISCOUNT PRESCRIPTIONS
Eligible medications will be available to all members at RxEDO’s pharmacy’s contracted rate
HELPFUL HINTS
•
Show the pharmacist your identification card. It includes the BIN # and PCN #, as well as any other
information they will need to process your claim through RxEDO.
•
If your pharmacy has any questions concerning the process, please have them call the RxEDO Pharmacy
Help Desk at For questions or drug look-up go to www.rxedo.com or call 1-888-879-7336.
For questions or drug look-up go to www.rxedo.com or call 1-888-879-7336.
38
REQUIRED NOTICES
39
IMPORTANT LEGAL NOTICES
AFFECTING YOUR 2024 HEALTH
PLAN COVERAGE
THE WOMEN’S HEALTH CANCER
RIGHTS ACT OF 1998 (WHCRA)
If you have had or are going to have a mastectomy,
you may be entitled to certain benefits under the
Women’s Health and Cancer Rights Act of 1998
(WHCRA). For individuals receiving mastectomy-
related benefits, coverage will be provided in a
manner determined in consultation with the attending
physician and the patient, for:
• 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; and
• Treatment of physical complications of the
mastectomy, including lymphedema.
These benefits will be provided subject to the same
deductibles and coinsurance applicable to other
medical and surgical benefits provided under this
plan. Therefore, the following in-network deductibles
and coinsurance apply:
NOTICE OF SPECIAL ENROLLMENT
RIGHTS
If you are declining enrollment for yourself or your
dependents (including your spouse) because of other
health insurance or group health plan coverage, you
may be able to enroll yourself and your dependents
in this plan if you or your dependents lose eligibility
for that other coverage (or if the employer stops
contributing toward your or your dependents’ other
coverage). However, you must request enrollment
within 30 days after your or your dependents’
other coverage ends (or after the employer stops
contributing toward the other coverage).
In addition, if you have a new dependent as a result
of marriage, birth, adoption, or placement for
adoption, you may be able to enroll yourself and your
dependents. However, you must request enrollment
within 30 days after the marriage, birth, adoption, or
placement for adoption.
Further, if you decline enrollment for yourself or
eligible dependents (including your spouse) while
Medicaid coverage or coverage under a State CHIP
program is in eect, you may be able to enroll yourself
and your dependents in this plan if:
• coverage is lost under Medicaid or a State CHIP
program; or
• you or your dependents become eligible for a
premium assistance subsidy from the State.
In either case, you must request enrollment within
60 days from the loss of coverage or the date you
become eligible for premium assistance.
To request special enrollment or obtain more
information, contact the person listed at the end of
this summary.
PATIENT PROTECTION MODEL
DISCLOSURE
The Ruby Tuesday Operations LLC Health Plan
generally allows the designation of a primary care
provider. You have the right to designate any primary
care provider who participates in our network and
who is available to accept you or your family members
For information on how to select a primary care
provider, and for a list of the participating primary
care providers, contact BlueCross BlueShield of
Tennessee at (800)565-9140.
For children, you may designate a pediatrician as the
primary care provider.
MICHELLE’S LAW DISCLOSURE
Under the ACA, dependent children are covered by
the group health plan until age 26. The Ruby Tuesday
Operations LLC Health Plan extends dependent
coverage beyond the ACA requirements, to age 26,
so long as the child is covered as a student. If your
child has extended coverage as a student but loses
IN-NETWORK
DEDUCTIBLE
IN-NETWORK
COINSURANCE
INDIVIDUAL FAMILY
BCBST HRA
Premier Care
- PPO
$2,800 $8,400 80%
BCBST High
Deductible –
EPO HSA
$3,200 $6,400 70%
BCBST Low
Deductible –
PPO HSA
$1,750 $3,500 80%
NEWBORNS ACT DISCLOSURE
- FEDERAL
Group health plans and health insurance issuers
generally may not, under Federal law, restrict benefits
for any hospital length of stay in connection with
childbirth 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). In any case, plans and issuers may not,
under Federal law, require that a provider obtain
authorization from the plan or the insurance issuer for
prescribing a length of stay not in excess of 48 hours
(or 96 hours).
40
their student status because they take a medically
necessary leave of absence from school your child
may continue to be covered under the plan for up to
one year from the beginning of the leave of absence.
This is available if, immediately before the first day
of the leave of absence, your child was (1) covered
under the plan and (2) enrolled as a student at a post-
secondary educational institution (includes colleges
and universities).
To obtain more information, contact the person listed
at the end of this summary.
STATEMENT OF ERISA RIGHTS
As a participant in the Plan you are entitled to certain
rights and protections under the Employee Retirement
Income Security Act of 1974 (“ERISA”). ERISA provides
that all participants shall be entitled to:
RECEIVE INFORMATION ABOUT YOUR PLAN
AND BENEFITS
• Examine, without charge, at the Plan
Administrator’s oce and at other specified
locations, the Plan and Plan documents, including
the insurance contract and copies of all documents
filed by the Plan with the U.S. Department of Labor,
if any, such as annual reports and Plan descriptions.
• Obtain copies of the Plan documents and other
Plan information upon written request to the Plan
Administrator. The Plan Administrator may make a
reasonable charge for the copies.
• Receive a summary of the Plan’s annual financial
report, if required to be furnished under ERISA.
The Plan Administrator is required by law to furnish
each participant with a copy of this summary
annual report, if any.
CONTINUE GROUP HEALTH PLAN COVERAGE
If applicable, you may continue health care coverage
for yourself, spouse or dependents if there is a loss
of coverage under the plan as a result of a qualifying
event. You and your dependents may have to pay for
such coverage. Review the summary plan description
and the documents governing the Plan for the rules
on COBRA continuation of coverage rights.
PRUDENT ACTIONS BY PLAN FIDUCIARIES
In addition to creating rights for participants, ERISA
imposes duties upon the people who are responsible
for operation of the Plan. These people, called
“fiduciaries” of the Plan, have a duty to operate the
Plan prudently and in the interest of you and other
Plan participants.
No one, including the Company or any other person,
may fire you or discriminate against you in any way
to prevent you from obtaining welfare benefits or
exercising your rights under ERISA.
ENFORCE YOUR RIGHTS
If your claim for a welfare benefit is denied in whole
or in part, you must receive a written explanation of
the reason for the denial. You have a right to have the
Plan review and reconsider your claim.
Under ERISA, there are steps you can take to enforce
these rights. For instance, if you request materials
from the Plan Administrator and do not receive
them within 30 days, you may file suit in federal
court. In such a case, the court may require the Plan
Administrator to provide the materials and pay you
up to $110 per day, until you receive the materials,
unless the materials were not sent due to reasons
beyond the control of the Plan Administrator. If you
have a claim for benefits which is denied or ignored, in
whole or in part, and you have exhausted the available
claims procedures under the Plan, you may file suit
in a state or federal court. If it should happen that
Plan fiduciaries misuse the Plan’s money, or if you are
discriminated against for asserting your rights, you
may seek assistance from the U.S. Department of
Labor, or you may file suit in a federal court. The court
will decide who should pay court costs and legal fees.
If you are successful, the court may order the person
you have sued to pay these costs and fees. If you lose
(for example, if the court finds your claim is frivolous)
the court may order you to pay these costs and fees.
ASSISTANCE WITH YOUR QUESTIONS
If you have any questions about your Plan, this
statement, or your rights under ERISA, you should
contact the nearest oce of the Employee Benefits
and Security Administration, U.S. Department of
Labor, listed in your telephone directory or the
Division of Technical Assistance and Inquiries,
Employee Benefits and Security Administration, U.S.
Department of Labor, 200 Constitution Avenue N.W.,
Washington, D.C. 20210.
CONTACT INFORMATION
Questions regarding any of this information can be
directed to:
Benefits Administration
210 Simmons Street
Maryville, TN 37801
benefitsadministration@rubytuesday.com
THIS NOTICE DESCRIBES HOW
MEDICAL INFORMATION ABOUT YOU
MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT
CAREFULLY.
41
YOUR INFORMATION. YOUR RIGHTS.
OUR RESPONSIBILITIES.
Recipients of the notice are encouraged to read the
entire notice. Contact information for questions or
complaints is available at the end of the notice.
YOUR RIGHTS
You have the right to:
• Get a copy of your health and claims records
• Correct your health and claims records
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared
your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights
have been violated
YOUR CHOICES
You have some choices in the way that we use and
share information as we:
• Answer coverage questions from your family
and friends
• Provide disaster relief
• Market our services and sell your information
OUR USES AND DISCLOSURES
We may use and share your information as we:
• Help manage the health care treatment you receive
• Run our organization
• Pay for your health services
• Administer your health plan
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests and
work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement,
and other government requests
• Respond to lawsuits and legal actions
YOUR RIGHTS
When it comes to your health information, you have
certain rights. This section explains your rights and
some of our responsibilities to help you.
Get a copy of health and claims records
• You can ask to see or get a copy of your health and
claims records and other health information we
have about you. Ask us how to do this.
• We will provide a copy or a summary of your health
and claims records, usually within 30 days of your
request. We may charge a reasonable, cost-based fee.
Ask us to correct health and claims records
• You can ask us to correct your health and
claims records if you think they are incorrect or
incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you
why in writing, usually within 60 days.
Request confidential communications
• You can ask us to contact you in a specific way (for
example, home or oce phone) or to send mail to a
dierent address.
• We will consider all reasonable requests, and must
say “yes” if you tell us you would be in danger if we
do not.
Ask us to limit what we use or share
• You can ask us not to use or share certain health
information for treatment, payment, or our operations.
• We are not required to agree to your request.
Get a list of those with whom we’ve shared
information
• You can ask for a list (accounting) of the times
we’ve shared your health information for up to six
years prior to the date you ask, who we shared it
with, and why.
• We will include all the disclosures except for
those about treatment, payment, and health care
operations, and certain other disclosures (such
as any you asked us to make). We’ll provide
one accounting a year for free but will charge a
reasonable, cost-based fee if you ask for another
one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any
time, even if you have agreed to receive the notice
electronically. We will provide you with a paper
copy promptly.
Choose someone to act for you
• If you have given someone medical power of
attorney or if someone is your legal guardian, that
person can exercise your rights and make choices
about your health information.
• We will make sure the person has this authority and
can act for you before we take any action.
File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your
rights by contacting us using the information at the
end of this notice.
• You can file a complaint with the U.S. Department
of Health and Human Services Oce for Civil
Rights by sending a letter to 200 Independence
Avenue, S.W., Washington, D.C. 20201, calling 1-877-
696-6775, or visiting www.hhs.gov/ocr/privacy/
hipaa/complaints/.
• We will not retaliate against you for filing a complaint.
42
YOUR CHOICES
For certain health information, you can tell us your
choices about what we share. If you have a clear
preference for how we share your information in the
situations described below, talk to us. Tell us what you
want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to
tell us to:
• Share information with your family, close friends, or
others involved in payment for your care
• Share information in a disaster relief situation
If you are not able to tell us your preference, for
example if you are unconscious, we may go ahead
and share your information if we believe it is in your
best interest. We may also share your information
when needed to lessen a serious and imminent
threat to health or safety.
• In these cases we never share your information
unless you give us written permission:
Marketing purposes
Sale of your information
OUR USES AND DISCLOSURES
How do we typically use or share your health
information?
We typically use or share your health information in
the following ways.
Help manage the health care treatment you receive
We can use your health information and share it with
professionals who are treating you.
Example: A doctor sends us information about your
diagnosis and treatment plan so we can arrange
additional services.
Pay for your health services
We can use and disclose your health information as
we pay for your health services.
Example: We share information about you with your
dental plan to coordinate payment for your dental
work.
Administer your plan
We may disclose your health information to your
health plan sponsor for plan administration.
Example: Your company contracts with us to provide
a health plan, and we provide your company with
certain statistics to explain the premiums we charge.
Run our organization
• We can use and disclose your information to run
our organization and contact you when necessary.
• We are not allowed to use genetic information to
decide whether we will give you coverage and the
price of that coverage. This does not apply to long
term care plans.
Example: We use health information about you to
develop better services for you.
How else can we use or share your health
information?
We are allowed or required to share your information
in other ways – usually in ways that contribute to the
public good, such as public health and research. We
have to meet many conditions in the law before we
can share your information for these purposes. For
more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/
consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain
situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic
violence
• Preventing or reducing a serious threat to anyone’s
health or safety
Do research
We can use or share your information for health
research.
Comply with the law
We will share information about you if state or federal
laws require it, including with the Department of
Health and Human Services if it wants to see that
we’re complying with federal privacy law.
Respond to organ and tissue donation requests and
work with a medical examiner or funeral director
• We can share health information about you with
organ procurement organizations.
• We can share health information with a coroner,
medical examiner, or funeral director when an
individual dies.
Address workers’ compensation, law enforcement,
and other government requests
We can use or share health information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law
enforcement ocial
• With health oversight agencies for activities
authorized by law
• For special government functions such as military,
national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in
response to a court or administrative order, or in
response to a subpoena.
43
Our Responsibilities
• We are required by law to maintain the privacy and
security of your protected health information.
• We will let you know promptly if a breach occurs
that may have compromised the privacy or security
of your information.
• We must follow the duties and privacy practices
described in this notice and give you a copy of it.
• We will not use or share your information other than
as described here unless you tell us we can in
writing. If you tell us we can, you may change your
mind at any time. Let us know in writing if you
change your mind.
For more information see: www.hhs.gov/ocr/privacy/
hipaa/understanding/consumers/noticepp.html.
CHANGES TO THE TERMS OF THIS NOTICE
We can change the terms of this notice, and the changes
will apply to all information we have about you. The new
notice will be available upon request, on our web site (if
applicable), and we will mail a copy to you.
OTHER INSTRUCTIONS FOR NOTICE
• Eective Date 01/01/2024
• Benefits Administration
210 Simmons Street
Maryville, TN 37801
IMPORTANT NOTICE FROM
RUBY TUESDAY ABOUT
YOUR PRESCRIPTION DRUG
COVERAGE AND MEDICARE
Please read this notice carefully and keep it where
you can find it. This notice has information about
your current prescription drug coverage with Ruby
Tuesday and about your options under Medicare’s
prescription drug coverage. This information
can help you decide whether or not you want to
join a Medicare drug plan. If you are considering
joining, you should compare your current coverage,
including which drugs are covered at what cost,
with the coverage and costs of the plans oering
Medicare prescription drug coverage in your area.
Information about where you can get help to make
decisions about your prescription drug coverage is
at the end of this notice.
There are two important things you need to know
about your current coverage and Medicare’s
prescription drug coverage:
1. Medicare prescription drug coverage became
available in 2006 to everyone with Medicare.
You can get this coverage if you join a Medicare
Prescription Drug Plan or join a Medicare
Advantage Plan (like an HMO or PPO) that oers
prescription drug coverage. All Medicare drug
plans provide at least a standard level of coverage
set by Medicare. Some plans may also oer more
coverage for a higher monthly premium.
2. Ruby Tuesday has determined that the
prescription drug coverage oered by the Cigna
and Kaiser CA plan(s) is, on average for all plan
participants, expected to pay out as much as
standard Medicare prescription drug coverage
pays and is therefore considered Creditable
Coverage. Because your existing coverage is
Creditable Coverage, you can keep this coverage
and not pay a higher premium (a penalty) if you
later decide to join a Medicare drug plan.
WHEN CAN YOU JOIN A MEDICARE DRUG
PLAN?
You can join a Medicare drug plan when you first
become eligible for Medicare and each year from
October 15th to December 7th.
However, if you lose your current creditable
prescription drug coverage, through no fault of your
own, you will also be eligible for a two (2) month
Special Enrollment Period (SEP) to join a Medicare
drug plan.
WHAT HAPPENS TO YOUR CURRENT
COVERAGE IF YOU DECIDE TO JOIN A
MEDICARE DRUG PLAN?
If you decide to join a Medicare drug plan, your
current Ruby Tuesday coverage will not be aected.
If you do decide to join a Medicare drug plan and
drop your current Ruby Tuesday coverage, be aware
that you and your dependents will be able to get this
coverage back.
WHEN WILL YOU PAY A HIGHER PREMIUM
(PENALTY) TO JOIN A MEDICARE DRUG PLAN?
You should also know that if you drop or lose your
current coverage with Ruby Tuesday and don’t join a
Medicare drug plan within 63 continuous days after
your current coverage ends, you may pay a higher
premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without
creditable prescription drug coverage, your monthly
premium may go up by at least 1% of the Medicare base
beneficiary premium per month for every month that
you did not have that coverage. For example, if you
go nineteen months without creditable coverage, your
premium may consistently be at least 19% higher than
the Medicare base beneficiary premium. You may have
to pay this higher premium (a penalty) as long as you
have Medicare prescription drug coverage. In addition,
you may have to wait until the following October to join.
FOR MORE INFORMATION ABOUT THIS NOTICE
OR YOUR CURRENT PRESCRIPTION DRUG
COVERAGE …
Contact the person listed below for further
information. NOTE: You’ll get this notice each year.
You will also get it before the next period you can join
a Medicare drug plan, and if this coverage through
Ruby Tuesday changes. You also may request a copy
of this notice at any time.
44
FOR MORE INFORMATION ABOUT YOUR
OPTIONS UNDER MEDICARE PRESCRIPTION
DRUG COVERAGE ...
More detailed information about Medicare plans that
oer prescription drug coverage is in the “Medicare &
You” handbook. You’ll get a copy of the handbook in
the mail every year from Medicare. You may also be
contacted directly by Medicare drug plans.
For more information about Medicare prescription
drug coverage:
• Visit www.medicare.gov
• Call your State Health Insurance Assistance
Program (see the inside back cover of your copy of
the “Medicare & You” handbook for their telephone
number) for personalized help
• Call 1-800-MEDICARE (1-800-633-4227). TTY users
should call 1-877-486-2048.
If you have limited income and resources, extra help
paying for Medicare prescription drug coverage is
available. For information about this extra help, visit
Social Security on the web at www.socialsecurity.gov,
or call them at 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If
you decide to join one of the Medicare drug plans,
you may be required to provide a copy of this notice
when you join to show whether or not you have
maintained creditable coverage and, therefore,
whether or not you are required to pay a higher
premium (a penalty).
Date: 01/01/2024
Name of Entity/Sender: Ruby Tuesday
Contact--Position/Oce: Benefits Administration
Address: 210 Simmons Street, Maryville, TN 37801
Phone Number: N/A
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.
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 oce 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 oce or
dial 1-877-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 1-866-444-EBSA (3272).
ALABAMA-MEDICAID
Website: http://myalhipp.com/
Phone: 1-855-692-5447
ALASKA-MEDICAID
The AK Health Insurance Premium Payment
Program Website: http://myakhipp.com/
Phone: 1-866-251-4861
Email: CustomerService@MyAKHIPP.com
Medicaid Eligibility:
https://health.alaska.gov/dpa/Pages/default.aspx
ARKANSAS-MEDICAID
Website: http://myarhipp.com/
Phone: 1-855-MyARHIPP (855-692-7447)
CALIFORNIA-MEDICAID
Website:
Health Insurance Premium Payment (HIPP) Program
http://dhcs.ca.gov/hipp
Phone: 916-445-8322
Fax: 916-440-5676
Email: hipp@dhcs.ca.gov
COLORADO-HEALTH FIRST COLORADO
(COLORADO’S MEDICAID PROGRAM) &
CHILD HEALTH PLAN PLUS (CHP+)
Health First Colorado Website:
https://www.healthfirstcolorado.com/
HealthFirstColoradoMemberContactCenter:
1-800-221-3943/StateRelay711
CHP+:
https://hcpf.colorado.gov/child-health-plan-plus
CHP+ Customer Service: 1-800-359-1991/State Relay 711
Health Insurance Buy-In Program (HIBI):
https://www.mycohibi.com/
HIBI Customer Service: 1-855-692-6442
FLORIDA-MEDICAID
Website: https://www.flmedicaidtplrecovery.com/
flmedicaidtplrecovery.com/hipp/index.html
Phone: 1-877-357-3268
45
GEORGIA-MEDICAID
GA HIPP Website: https://medicaid.georgia.gov/
health-insurance-premium-payment-program-hipp
Phone: 678-564-1162, Press 1
GA CHIPRA Website:
https://medicaid.georgia.gov/programs/third-
party-liability/childrens-health-insurance-program-
reauthorization-act-2009-chipra
Phone: (678) 564-1162, Press 2
INDIANA-MEDICAID
Healthy Indiana Plan for low-income adults 19-64
Website:
http://www.in.gov/fssa/hip/
Phone: 1-877-438-4479
All other Medicaid
Website: https://www.in.gov/medicaid/
Phone 1-800-457-4584
IOWA-MEDICAID AND CHIP (HAWKI)
Medicaid Website:
https://dhs.iowa.gov/ime/members Medicaid
Phone: 1-800-338-8366
Hawki Website: http://dhs.iowa.gov/Hawki
Hawki Phone: 1-800-257-8563
HIPP Website:
https://dhs.iowa.gov/ime/members/medicaid-
a-to-z/hipp
HIPP Phone: 1-888-346-9562
KANSAS-MEDICAID
Website: https://www.kancare.ks.gov/
Phone: 1-800-792-4884
HIPP Phone: 1-800-967-4660
KENTUCKY-MEDICAID
Kentucky Integrated Health Insurance Premium
Payment Program (KI-HIPP) Website: https://chfs.
ky.gov/agencies/dms/member/Pages/kihipp.aspx
Phone: 1-855-459-6328
Email: KIHIPP.PROGRAM@ky.gov
KCHIP Website:
https://kidshealth.ky.gov/Pages/index.aspx
Phone: 1-877-524-4718
Kentucky Medicaid Website:
https://chfs.ky.gov/agencies/dms
LOUISIANA-MEDICAID
Website: www.medicaid.la.gov or www.ldh.la.gov/
lahipp
Phone: 1-888-342-6207 (Medicaid hotline) or
1-855-618-5488 (LaHIPP)
MAINE-MEDICAID
Enrollment Website:
https://www.mymaineconnection.gov/benefits/
s/?language=en_US
Phone: 1-800-442-6003
TTY: Maine relay 711
Private Health Insurance Premium Webpage:
https://www.maine.gov/dhhs/ofi/applications-
forms
Phone: -800-977-6740.
TTY: Maine relay 711
MASSACHUSETTS-MEDICAID AND CHIP
Website: https://www.mass.gov/masshealth/pa
Phone: 1-800-862-4840
TTY: 711
Email: masspremassistance@accenture.com
MINNESOTA-MEDICAID
Website:
https://mn.gov/dhs/people-we-serve/children-
and-families/health-care/health-care-programs/
programs-and-services/other-insurance.jsp
Phone: 1-800-657-3739
MISSOURI-MEDICAID
Website:
http://www.dss.mo.gov/mhd/participants/pages/
hipp.htm
Phone: 573-751-2005
MONTANA-MEDICAID
Website:
http://dphhs.mt.gov/MontanaHealthcarePrograms/
HIPP
Phone: 1-800-694-3084
Email: HHSHIPPProgr[email protected]
NEBRASKA-MEDICAID
Website: http://www.ACCESSNebraska.ne.gov
Phone: 1-855-632-7633
Lincoln: 402-473-7000
Omaha: 402-595-1178
NEVADA-MEDICAID
Medicaid Website: http://dhcfp.nv.gov
Medicaid Phone: 1-800-992-0900
NEW HAMPSHIRE-MEDICAID
Website: https://www.dhhs.nh.gov/programs-
services/medicaid/health-insurance-premium-
program
Phone: 603-271-5218
Toll free number for the HIPP program:
1-800-852-3345, ext 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: 1-800-701-0710
NEW YORK-MEDICAID
Website: https://www.health.ny.gov/health_care/
medicaid/
Phone: 1-800-541-2831
NORTH CAROLINA-MEDICAID
Website: https://medicaid.ncdhhs.gov/
Phone: 919-855-4100
NORTH DAKOTA-MEDICAID
Website: https://www.hhs.nd.gov/healthcare
Phone: 1-844-854-4825
46
OKLAHOMA-MEDICAID AND CHIP
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
OREGON-MEDICAID
Website:
http://healthcare.oregon.gov/Pages/index.aspx
Phone: 1-800-699-9075
PENNSYLVANIA-MEDICAID
Website: https://www.dhs.pa.gov/Services/
Assistance/Pages/HIPP-Program.aspx
Phone: 1-800-692-7462
CHIP Website: https://www.dhs.pa.gov/CHIP/
Pages/CHIP.aspx
CHIP Phone: 1-800-986-KIDS (5437)
RHODE ISLAND-MEDICAID AND CHIP
Website: http://www.dss.mo.gov/mhd/participants/
pages/hipp.htm
Phone: 1-855-697-4347, or 401-462-0311
(Direct RIte Share Line)
SOUTH CAROLINA-MEDICAID
Website: https://www.scdhhs.gov
Phone: 1-888-549-0820
SOUTH DAKOTA-MEDICAID
Website: http://dss.sd.gov
Phone: 1-888-828-0059
TEXAS-MEDICAID
Website: https://www.hhs.texas.gov/services/
financial/health-insurance-premium-payment-
hipp-program
Phone: 1-800-440-0493
UTAH-MEDICAID AND CHIP
Medicaid Website: https://medicaid.utah.gov/
CHIP Website: http://health.utah.gov/chip
Phone: 1-877-543-7669
VERMONT-MEDICAID
Website: https://dvha.vermont.gov/members/
medicaid/hipp-program
Phone: 1-800-250-8427
VIRGINIA-MEDICAID AND CHIP
Website: https://coverva.dmas.virginia.gov/learn/
premium-assistance/famis-select
https://coverva.dmas.virginia.
gov/learn/premium-assistance/
health-insurance-premium-payment-hipp-programs
Medicaid/CHIP Phone: 1-800-432-5924
WASHINGTON-MEDICAID
Website: https://www.hca.wa.gov/
Phone: 1-800-562-3022
WEST VIRGINIA-MEDICAID AND CHIP
Website: https://dhhr.wv.gov/bms/
http://mywvhipp.com/
Medicaid Phone: 304-558-1700
CHIP Toll-free phone: 1-855-MyWVHIPP
(1-855-699- 8447)
WISCONSIN-MEDICAID AND CHIP
Website: https://www.dhs.wisconsin.gov/
badgercareplus/p- 10095.htm
Phone: 1-800-362-3002
WYOMING-MEDICAID
Website: https://health.wyo.gov/healthcarefin/
medicaid/programs-and-eligibility/
Phone: 1-800-251-1269
To see if any other states have added a premium
assistance program since January 31, 2023, or for more
information on special enrollment rights, contact either:
U.S. Department of Labor
Employee Benefits Security Administration
www.dol.gov/agencies/ebsa
1-866-444-EBSA (3272)
U.S. Department of Health and Human Services Centers
for Medicare & Medicaid Services
www.cms.hhs.gov
1-877-267-2323, Menu Option 4, Ext. 61565
PAPERWORK REDUCTION ACT
STATEMENT
According to the Paperwork Reduction Act of 1995 (Pub.
L. 104-13) (PRA), no persons are required to respond
to a collection of information unless such collection
displays a valid Oce of Management and Budget
(OMB) control number. The Department notes that a
Federal agency cannot conduct or sponsor a collection
of information unless it is approved by OMB under
the PRA, and displays a currently valid OMB control
number, and the public is not required to respond to a
collection of information unless it displays a currently
valid OMB control number. See 44 U.S.C. 3507. Also,
notwithstanding any other provisions of law, no person
shall be subject to penalty for failing to comply with a
collection of information if the collection of information
does not display a currently valid OMB control number.
See 44 U.S.C. 3512.
The public reporting burden for this collection of
information is estimated to average approximately
seven minutes per respondent. Interested parties are
encouraged to send comments regarding the burden
estimate or any other aspect of this collection of
information, including suggestions for reducing this
burden, to the U.S. Department of Labor, Employee
Benefits Security Administration, Oce of Policy
and Research, Attention: PRA Clearance Ocer, 200
Constitution Avenue, N.W., Room N-5718, Washington, DC
20210 or email ebsa.[email protected]v and reference the OMB
Control Number 1210-0137.
OMB Control Number 1210-0137 (expires 1/31/2026)
47
PART A: GENERAL INFORMATION
When key parts of the health care law take eect in 2014, there will be 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 new Marketplace and employment based health coverage oered
by your employer.
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 oers “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 October 2013 for coverage starting as early as
January 1, 2014.
CAN I SAVE MONEY ON MY HEALTH INSURANCE PREMIUMS IN THE MARKETPLACE?
You may qualify to save money and lower your monthly premium, but only if your employer does not oer
coverage, or oers coverage that doesn’t meet certain standards. The savings on your premium that you’re eligible
for depends on your household income.
DOES EMPLOYER HEALTH COVERAGE AFFECT ELIGIBILITY FOR PREMIUM SAVINGS THROUGH THE
MARKETPLACE?
Yes. If you have an oer of health coverage from your employer that meets certain standards, you will not be
eligible for a tax credit through the Marketplace and may wish to enroll in your employer’s health plan. However,
you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if
your employer does not oer coverage to you at all or does not oer coverage that meets certain standards. If
the cost of a plan from your employer that would cover you (and not any other members of your family) is more
than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the
“minimum value” standard set by the Aordable Care Act, you may be eligible for a tax credit.
1
Note: If you purchase a health plan through the Marketplace instead of accepting health coverage oered by
your employer, then you may lose the employer contribution (if any) to the employer-oered coverage. Also, this
employer contribution -as well as your employee contribution to employer-oered 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 oered by your employer, please check your summary plan description
or contact.
The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the
Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for
health insurance coverage and contact information for a Health Insurance Marketplace in your area.
NEW HEALTH INSURANCE MARKETPLACE
COVERAGE OPTIONS AND YOUR HEALTH
COVERAGE
Form Approved
OMBNo.1210-0149
(expires 6-30-2024)
48
4 If checked, this coverage meets the minimum value standard*, and the cost of this coverage to you is
intended to be aordable, based on employee wages.
** Even if your employer intends your coverage to be aordable, you may still be eligible for a premium
discount through the Marketplace. The Marketplace will use your household income, along with other factors, to
determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to
week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-
year, or if you have other income losses, you may still qualify for a premium discount.
If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here’s
the employer information you’ll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower
your monthly premiums.
• 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 36 B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
PART B: INFORMATION ABOUT HEALTH COVERAGE OFFERED BY
YOUR EMPLOYER
This section contains information about any health coverage oered by your employer. 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
Ruby Tuesday
4. Employer Identification Number (EIN)
63-0475239
5. Employer address
210 Simmons Street
6. Employer phone number
N/A
7. City
Maryville
8. State
TN
9. Zip code
37801
10. Who can we contact about employee health coverage at this job?
Benefits Administration
11. Phone number (if dierent from above)
N/A
12. Email address
benefitsadministration@rubytuesday.com
Here is some basic information about health coverage oered by this employer:
• As your employer, we oer a health plan to:
4 All employees. Eligible employees are:
Full Time & Part Time employees
• With respect to dependents:
4 We do oer coverage. Eligible dependents are:
Spouse, Domestic Partners, Children up to age 26, Children who are mentally or physically unable to
care for themselves.
49
NOTES
50
NOTES
51
NOTES
2024 WELLNESS AND BENEFITS GUIDE
210 SIMMONS STREET
MARYVILLE, TENNESSEE 37801
This brochure summarizes the benefit plans that are available to Ruby Tuesday eligible employees and their
dependents. Ocial plan documents, policies and certificates of insurance contain the details, conditions,
maximum benefit levels and restrictions on benefits. These documents govern your benefits program. If there
is any conflict, the ocial documents prevail. These documents are available upon request through the Human
Resources Department. Information provided in this brochure is not a guarantee of benefits.
