Flexible Spending Accounts. Maximize your benefits and give yourself a raise.

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1 Flexible Spending Accounts Maximize your benefits and give yourself a raise.

2 Flexible Spending Plans A Cafeteria Plan enables you to save money on group insurance, health-related expenses, and dependent-care expenses. Your contributions are deducted from your pay before taxes are withheld. Because you are taxed on a lower amount of pay, you pay less in taxes and you have more to spend. You may save as much as 35 percent on the cost of each benefit option! FSA Savings FSA Savings Comparison FSA No FSA Annual Taxable Income $24,000 $24,000 Out of Pocket Expenses Health Care Expenses $1,500 $0 Dependent Day Care Expenses $1,500 $0 Total Pre-Tax Contributions ($3,000) $0 Taxable Income After FSA $21,000 $24,000 Federal, State, & SS Taxes (30+%) ($6,300) ($7,200) Typical Savings After-Tax Income $14,700 $16,800 FICA 7.65% After-Tax Dollars spent on health/ dep care expenses $0 $3,000 State Tax* 7.10% Take-Home Pay $14,700 $13,800 Fed. Tax* 15.00% Increased Take-Home Pay $900 $0 30% Savings *Federal and State Tax savings may vary. A savings calculator can be found on our website: NBSbenefits.com to find out how much you could save. Partial List of Eligible Expenses: Medical/dental/vision co-pays and deductibles Prescription drugs Physical therapy Chiropractor First aid supplies Lab fees Psychiatrist/psychologist Vaccinations Dental work, including orthodontia Eye exams Laser eye surgery Eye glasses, contact lenses, lens solution Prescribed OTC Medications See the full list at Enrollment Options Health Care Expense Account Your health care expense account allows you to save money by paying out-of-pocket health-related expenses with pre-tax dollars. During your annual benefit enrollment, you must decide whether to participate in this account and how much to contribute. Dependent Care Account (Day Care Expenses) This optional plan allows you to use pre-tax dollars to pay for dependentcare expenses while you and your spouse (if married) are at work. During the annual benefit enrollment, you must decide whether to participate in this account and how much to contribute. The dependent care account is not pre-funded. You are eligible for reimbursement once you have incurred a claim and money has been deducted from your paycheck.

3 How the FSA Plan Works You designate an annual election of pre-tax dollars to be deposited into your health and dependent-care spending accounts. Your total election is divided by the number of pay periods in the Plan year and deducted equally from each paycheck before taxes are calculated. By the end of the Plan year, your total election will be fully deposited. However, you may make a claim for eligible health FSA expenses as soon as they are incurred during the Plan year. Eligible claims will be paid up to your total annual election even if you have not yet contributed that amount to your account. Get Your Money 1. Complete and sign a claim form (available on our website) or an online webclaim. 2. Attach documentation; such as an itemized bill or an Explanation of Benefits (EOB) statement from a health insurance provider. 3. Fax or mail signed form and documentation to NBS. 4. Receive your non-taxable reimbursement after your claim is processed either by check or direct deposit. NBS Flexcard FSA Pre-paid Your employer may sponsor the use of the NBS Flexcard, making access to your flex dollars easier than ever. You may use the card to pay merchants or service providers that accept credit cards, so there is no need to pay cash up front then wait for reimbursement. Account Information Participants may call NBS and talk to a representative during our regular business hours, Monday Friday, 7am to 6pm Mountain Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) or toll free (888) For immediate access to your account information at any time, log on to our website NBSbenefits.com. Information includes: Detailed claim history and processing status Health Care and Dependent Care account balances Claim forms, worksheets, etc. Online Claim Submission Enrollment Considerations After the the enrollment period ends, you may increase, decrease, or stop your contribution only when you experience a qualifying change of status (marriage status, employment change, dependent change). Be conservative in the total amount you elect to avoid forfeiting money that may be left in your account at the end of the year. Your employer may allow a short grace period after the Plan year ends for you to submit qualified claims for any unused funds. NATIONAL BENEFIT SERVICES, LLC 8523 South Redwood Road West Jordan, UT Phone: Fax: Service@NBSbenefits.com NBSbenefits.com

4 Know Your Health Care FSA/HRA Eligible and Ineligible Expenses Maximize the Value of Your Reimbursement Account Your Health Care Flexible Spending Account (FSA) and/or Health Reimbursement Account (HRA) 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 (as of ). 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 LAB 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 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.

5 The IRS does not allow the following expenses to be reimbursed under Health Care FSAs or HRAs, as they are not prescribed by a physician for a specific ailment. Ineligible Expenses Contact Lens or Eyeglass Insurance Cosmetic Surgery/Procedures Electrolysis 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 Note: This list is not meant to be all-inclusive. Please Note: The IRS will not allow OTC medicines or drugs to be purchased with Health Care FSA or HRA funds unless accompanied by a prescription. However, there will be no definite identification as to which OTC items are considered to be medicine or drugs until We will update this list at that time. Eligible Over-the-Counter Items Note: Product categories are listed in bold face; common examples of products are listed in regular face. The following is a high level list of Over-the-Counter (OTC) items that clearly are not medicine or drugs and are eligible for purchase with Health Care FSA or HRA dollars. You can use your benefits card for these items Antiseptics, Wound Cleansers Alcohol, peroxide, Epsom salt, Baby Electrolytes Pedialyte, Enfalyte Denture Adhesives, Repair, and Cleansers PoliGrip, Benzodent, Efferdent Diabetes Testing and Aids Insulin, Ascencia, One Touch, Diabetic Tussin, insulin syringes; glucose products Diagnostic Products Thermometers, blood pressure monitors, cholesterol testing 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 Hearing Aid/Medical Batteries Incontinence Products Attends, Depend, GoodNites for juvenile incontinence Reading Glasses and Maintenance Accessories For additional information, please contact your Plan Administrator.