Congratulations on choosing the convenience of

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1 Congratulations on choosing the convenience of to access your Flexible Spending Account (FSA). It s the easy way to pay for qualified health care expenses without having to pay cash up-front. Your Card does not have a PIN. Select Credit when asked, Credit or Debit? and sign for your purchase. Questions? Check your balance? Need additional Cards? Contact your Plan Administrator at the phone number or web site listed on the back of the Card.

2 Using Your Benny Prepaid MasterCard makes FSAs Fast, Easy, Automatic! Before Using Your Card: Know what accounts you have. Know which accounts you can use with the Card. STEP 1: Activate and sign your Card(s). To activate your Card, follow the instructions on the Card sticker. For activating, your member ID is usually your Social Security Number or Health Plan Member ID number. Sign the back of your Card and have the other eligible user sign the other Card. Once activated, you will have full access to your FSA health care amount on your plan effective date. Don t throw your Cards out at the end of the plan year as they will be reloaded with the new plan year election. STEP 2: Use your Card for current plan year qualified expenses only, for you and your dependents. For prescriptions and eligible over-the-counter (OTC) expenses: Visit the web site on the back of your Card or consult your Plan Administrator for the merchant list of pharmacies, discount stores, department stores and supermarkets where you can use your Card. If a store is not on the merchant list, your Card may decline due to IRS regulations. Swipe your Card for the amount you owe for prescriptions and eligible over-the-counter (OTC) items covered by your health plan. Enter your Card number on mail order prescription invoices and online pharmacy statements. For medical, dental and vision expenses: Swipe your Card for health plan copayments, dental expenses, vision services and eyeglasses and co-insurance. Enter your Card number on Amount Due medical and dental statements. STEP 3: Save all itemized receipts. You may be contacted by your Plan Administrator to submit receipts to verify expenses comply with IRS rules. STEP 4: Check your account balances often. Check your balance via the web site or phone number on the back of your Card. Make sure you have sufficient funds in your account to cover your expenses. This document may not be used or copied except with express prior written consent of Evolution Benefits, Inc. This card is issued by The Bancorp Bank pursuant to license from MasterCard International Incorporated The Bancorp Bank; Member FDIC. MasterCard is a registered trademark of MasterCard International Incorporated Evolution Benefits, Inc. All rights reserved

3 Health Care & Dependent Care Expense Worksheet Use this worksheet to help you determine your Health Care FSA election amount. You may want to review receipts from last year for health care expenses you paid out of your own pocket. Using these receipts and this worksheet, you can estimate the amount you want to elect for the Health Care FSA, only budget for those expenses eligible for reimbursement through the Health Care FSA. Remember, eligible expenses include those for you, your spouse and your dependents. Deductibles Expenses NOT covered by Insurance Plan Medical, dental, vision Prescription Drug Over-the-counter medications (with prescription from Doctor) Copayments/coinsurance Vision Care Dental/orthodontic care The amount not paid by your health plan Treatments/therapies coverage Fees/services Medical Equipment Amounts paid over plan limits Psychiatric Care Assistance for the disabled The amount not paid by your plan due Other eligible expenses to plan limits Subtotal B Subtotal A Out-of-pocket Health Care Expenses This give you a good idea of the amount you should elect to place into your Health Care FSA. Consider any other factors that will affect your out-of-pocket health care costs during the upcoming plan year and adjust the amount necessary (Add Subtotals A + B) Dependent Care FSA Worksheet Use this worksheet to help determine your Dependent Care FSA election amount. The Dependent Care FSA allows you to use pre-tax dollars to pay for child care services that make it possible for you and your spouse (if applicable) to work. Under certain circumstances it also may be used to help pay for the care of elderly parents or a disabled spouse or dependent. Not that the Dependent Care FSA is intended to cover costs of care and does not cover any medical or healthcare costs for your dependents. Child Care Expenses Day Care Center In-home Care Nursery and Pre-School After School Care Summer Day Camps Elder Care Services Day Care Center In-home Care Out-of-pocket Dependent Care Expenses This total gives you an estimated amount that you should elect to place into your Dependent Care FSA. Remember, you will avoid Social Security and Medicare taxes on the money you set aside Total

4 Know Your Health Care FSA Eligible and Ineligible Expenses Maximize the Value of Your Reimbursement Account - Your Health Care Flexible Spending Account (FSA) dollars can be used for a variety of out-of-pocket health care expenses. The following is based on a list of eligible and ineligible expenses used by federal employees. Eligible Expenses BABY/CHILD TO AGE 13 Lactation Consultant* Lead-Based Paint Removal Special Formula* Tuition: Special School/Teacher for Disability or Learning Disability* Well Baby /Well Child Care DENTAL Dental X-Rays Dentures and Bridges Exams and Teeth Cleaning Extractions and Fillings Oral Surgery Orthodontia Periodontal Services EYES Eye Exams Eyeglasses and Contact Lenses Laser Eye Surgeries Prescription Sunglasses Radial Keratotomy HEARING Hearing Aids and Batteries Hearing Exams AB EXAMS/TESTS Blood Tests and Metabolism Tests Body Scans Cardiograms Laboratory Fees X-Rays MEDICAL EQUIPMENT/SUPPLIES Air Purification Equipment* Arches and Orthotic Inserts Contraceptive Devices Crutches, Walkers, Wheel Chairs Exercise Equipment* Hospital Beds* Mattresses* Medic Alert Bracelet or Necklace Nebulizers Orthopedic Shoes* Oxygen* Post-Mastectomy Clothing Prosthetics Syringes Wigs* MEDICAL PROCEDURES/SERVICES Acupuncture Alcohol and Drug/Substance Abuse (inpatient treatment and outpatient care) Ambulance Fertility Enhancement and Treatment Hair Loss Treatment* Hospital Services Immunization In Vitro Fertilization Physical Examination (not employment-related) Reconstructive Surgery (due to a congenital defect, accident, or medical treatment) Service Animals Sterilization/Sterilization Reversal Transplants (including organ donor) Transportation* MEDICATIONS Insulin Prescription Drugs OBSTETRICS Breast Pumps and Lactation Supplies Doulas* Lamaze Class OB/GYN Exams OB/GYN Prepaid Maternity Fees (reimbursable after date of birth) Pre- and Postnatal Treatments PRACTITIONERS Allergist Chiropractor Christian Science Practitioner Dermatologist Homeopath Naturopath* Optometrist Osteopath Physician Psychiatrist or Psychologist THERAPY Alcohol and Drug Addiction Counseling (not marital or career) Exercise Programs* Hypnosis Massage* Occupational Physical Smoking Cessation Programs* Speech Weight Loss Programs* HRA ELIGIBLE Insurance Premiums Long Term Care Premiums Note: This list is not meant to be all-inclusive, as other expenses not specifically mentioned may also qualify. Also, expenses marked with an asterisk (*) are potentially eligible expenses that require a Note of Medical Necessity from your health care provider to qualify for reimbursement. For additional information, check your Summary Plan Document or contact your Plan Administrator EVOLUTION1, INC. ALL RIGHTS RESERVED. EC-0913

5 The IRS does NOT allow the following expenses to be reimbursed under Health Care FSAs, as they are not prescribed by a physician for a specific ailment. Ineligible Expenses Contact Lens or Eyeglass Insurance Cosmetic Surgery/Procedures Electrolysis Note: This list is not meant to be all-inclusive. Insurance Premiums and Interest (FSA Ineligible Only) Long Term Care Premiums (FSA Ineligible Only) Marriage or Career Counseling Personal Trainers Sunscreen (spf less than 30) Swimming Lessons Please Note: The IRS does not allow Over-the-Counter (OTC) medicines or drugs to be purchased with Health Care FSA funds unless accompanied by a prescription and the prescription is filled by a pharmacist. If you have an OTC prescription, you can use your benefits card for these purchases. Ineligible Over-the-Counter Medicines and Drugs (unless prescribed in accordance with state laws) Acid controllers Acne medications Allergy & sinus Antibiotic products Antifungal (Foot) Antiparasitic treatments Antiseptics & wound cleansers Anti-diarrheals Anti-gas Anti-itch & insect bite Baby rash ointments & creams Baby teething pain Cold sore remedies Contraceptives Cough, cold & flu Denture pain relief Digestive aids Ear care Eye care Feminine antifungal & anti-itch Fiber laxatives (bulk forming) First aid burn remedies Foot care treatment Hemorrhoidal preps Homeopathic remedies Incontinence protection & treatment products Laxatives (non-fiber) Medicated nasal sprays, drops, & inhalers Medicated respiratory treatments & vapor products Motion sickness Oral remedies or treatments Pain relief (includes aspirin) Skin treatments Sleep aids & sedatives Smoking deterrents Stomach remedies Unmedicated vapor products OTC items that are not medicines or drugs remain eligible for purchase with FSAs. You can use your benefits card for these items. Eligible Over-the-Counter Items (Product categories are listed in bold face; common examples are listed in regular face.) Baby Electrolytes and Dehydration Pedialyte, Enfalyte Contraceptives Unmedicated condoms Denture Adhesives, Repair, and Cleansers PoliGrip, Benzodent, Plate Weld, Efferdent Diabetes Testing and Aids Ascencia, One Touch, Diabetic Tussin, insulin syringes; glucose products Diagnostic Products Thermometers, blood pressure monitors, cholesterol testing Ear Care Unmedicated ear drops, syringes, ear wax removal Elastics/Athletic Treatments ACE, Futuro, elastic bandages, braces, hot/cold therapy, orthopedic supports, rib belts Eye Care Contact lens care Family Planning Pregnancy and ovulation kits First Aid Dressings and Supplies Band Aid, 3M Nexcare, non-sport tapes Foot Care Treatment Unmedicated corn and callus treatments (e.g., callus cushions), devices, therapeutic insoles Glucosamine &/or Chondroitin Osteo-Bi-Flex, Cosamin D, Flex-a-min Nutritional Supplements Hearing Aid/Medical Batteries Home Health Care (limited segments) Ostomy, walking aids, decubitis/pressure relief, enteral/parenteral feeding supplies, patient lifting aids, orthopedic braces/supports, splints & casts, hydrocollators, nebulizers, electrotherapy products, catheters, unmedicated wound care, wheel chairs Incontinence Products Attends, Depend, GoodNites for juvenile incontinence, Prevail Nasal Care Saline Nasal Spray Prenatal Vitamins Stuart Prenatal, Nature's Bounty Prenatal Vitamins Reading Glasses and Maintenance Accessories For additional information, please contact your Plan Administrator EVOLUTION1, INC. ALL RIGHTS RESERVED. EC-0913