PayFlex Flexible Spending Accounts

PayFlex Flexible Spending Accounts Plan Year: January 1, 2016 through December 31, 2016 Health Care Reimbursement Account Maximum: $2,500 Health Care Reimbursement Account Minimum: $0 Dependent Care Reimbursement Account Maximum: $5000 A flexible spending account (FSA) lets you set aside money from your paycheck (on a pretax basis) to use for eligible outof-pocket expenses. The two most common types of FSAs are health care and dependent care. Health Care FSA This account reimburses you for various eligible health care expenses. These include medical, dental, vision, hearing and prescription drug expenses. You can also use the FSA funds to pay for copays, coinsurance and over-the-counter (OTC) items.* Dependent Care FSA This account reimburses you for eligible child and adult care expenses. Such expenses include day care, before and after school care, nursery school, preschool and summer day camp. The benefits of having an FSA An FSA can help reduce your taxes and increase your take home pay! The money you contribute to an FSA is exempt from federal taxes, as well as most state and payroll taxes. Learn more about FSAs Visit HealthHub.com and click on Employee Account Login to use the following tools: My HealthHub Resources: View educational materials, forms and IRS publications. Savings calculator: Estimate your health care and dependent care expenses. Getting started is easy! First, decide if you want to enroll in a health care and/or dependent care FSA. Then, review your expenses from last plan year and think about what you expect to spend this year. This will help you decide how much to contribute to a health care or dependent care FSA. Your employer will deduct your pretax contributions from your paycheck (in equal amounts during the year) and deposit into your FSA. FSA contribution limits The current annual health care FSA pretax contribution limit is $2,550.** If you and your spouse each have a health care FSA, you can each contribute $2,550. The dependent care FSA limit is $5,000** per household/ family. If you and your spouse each have a dependent care FSA, you are limited to $5,000 between the two of you. How to use your FSA funds If you pay for eligible expenses with cash, check or a personal credit card, you can submit an online request for reimbursement. Or you can fill out a paper claim form and fax or mail it to PayFlex. If offered by your employer, you may also use the PayFlex Card, your account debit card, to pay for your eligible expenses. When you use the card, the funds automatically come out of your FSA. Note: Save all of your receipts. If you have an Explanation of Benefits (EOB) from your insurance plan, save that too. When you submit a claim, you ll need to submit the EOB or receipt. Digital library: View an educational video about FSAs. * You will need a written prescription for OTC drugs and medicine. ** Some employers may set lower limits for their plans. Please check your plan for how much you can contribute to an FSA. 69.03.342.1 A (11/14) Page 31

What you need to know about FSAs FSAs have a use-it-or-lose-it rule. This means you forfeit any unused funds at the end of the plan year. If your plan has a grace period, you will have an additional 2 months and 15 days (after the plan year) to use your funds. The run out period provides you with additional days (after the end of your plan year) to submit claims for reimbursement. Please confirm the length of your run out period with your employer. You cannot change your contribution unless you have a change in status.* This may include a change in one or more of the following: Legal marital status (marriage, divorce, legal separation, annulment or death of a spouse) Number of tax dependents (birth, adoption or death) Employment status that affects eligibility Dependent satisfying or ceasing to satisfy coverage requirements (reaching limiting age, gain or loss of student status, marriage) Specific to a dependent care FSA, you can change your contribution if: There is a change in your provider There is a change in the cost for a provider (unless this provider is a relative) Stay connected to your FSA When you have an FSA, you can sign up for various alerts on your account. These will help you stay up to date on your account activity. PayFlex Mobile app Your employer may offer the PayFlex Mobile application for virtually 24/7 access to your account. The PayFlex Mobile app is free and available for most smartphones. The app lets you: Manage your account and submit claims View your account balance, payments and deposits Receive account alerts and submit documentation (if applicable) View a list of common eligible expense items General health care expense information You can only receive reimbursement for expenses incurred during the current plan year or grace period, if applicable. Reimbursement is for eligible expenses incurred by you, your spouse and your dependents. You cannot receive reimbursement for an eligible expense more than once. General dependent care expense information Dependent care expenses must be for a qualifying person. This includes your dependent who is younger than age 13, or a spouse or dependent incapable of self-care. To receive reimbursement, you must be working. If you are married, your spouse must either be working, looking for work, be a full-time student or incapable of self-care. Expenses are reimbursed based on the amount available in your account. Expense reimbursement is for services already received. Questions? Visit HealthHub.com. Or call us at 1-800-284-4885. Customer service representatives are available Monday through Friday from 7 a.m. to 7 p.m. CT and Saturday from 9 a.m. to 2 p.m. CT. * You must apply for a change in your election through your employer. You must submit your request generally within 30 days of your status change date. See your employer s Summary Plan Description for specific details applicable to your plan. This material is for informational purposes only. The information describes the Flexible Spending Account ( FSA ) in general terms. FSA plans are governed by the rules of Section 125 of the Internal Revenue Code and will be administered in accordance with those rules. Estimate fund amounts carefully. Unused funds will be forfeited either after the last day of the plan year or at the end of the grace period if your plan offers one. Eligible expenses may vary from employer to employer. In case of a conflict between your plan documents and the information in this material, the plan documents will govern. 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. For more information about PayFlex, go to HealthHub.com. 2014 PayFlex Systems USA, Inc. 69.03.342.1 A (11/14) Page 32

Using a Flexible Spending Account to pay for over-the-counter items If you want to use your Health Care Flexible Spending Account (FSA) to pay for eligible over-thecounter (OTC) items, there are a few things to keep in mind. You ll need a written prescription from your doctor to use your health care FSA for OTC drugs and medicines. The following is a partial list of OTC drugs and medicines that will need a prescription. Note: You don t need a prescription for insulin. OTC drugs & medicines that need a prescription o Acid Controllers o Allergy & Sinus o Antibiotic Products o Antidiarrheals o Anti-Gas o Anti-Itch & Insect Bite o Anti-Parasitic Treatments o Baby Rash Ointments/Creams o Cold Sore Remedies o Cough, Cold & Flu o Digestive Aids o Feminine Anti-Fungal/Anti-Itch o Hemorrhoid Preps o Laxatives o Motion Sickness o Pain Relief o Respiratory Treatments o Sleep Aids & Sedatives o Stomach Remedies You must have the written prescription before you buy the OTC product. Usually, you can t use a health care debit card to buy OTC drugs and medicines. This includes the PayFlex Card, your account debit card. If you try to use the card, the purchase may be denied at the store. You ll need to pay for it out-of-pocket. Then you can send a copy of the prescription along with a claim form to request reimbursement. Note: Your pharmacist may be able to process an OTC drug or medicine as a prescription and assign a prescription number. In that case, you could use the debit card. The OTC drug or medicine that you buy must be the same as the written prescription. Example: If you have a prescription for Tylenol and you buy Advil, the claim will be denied. Every time you send a claim to PayFlex for an OTC medicine or drug, you need to send the prescription. This is true even if it s a recurring expense. The following is a partial list of OTC items that don t require a prescription to be reimbursed from your health care FSA. Please refer to your employer s plan document for items allowed under your plan. OTC items that don t need a prescription o Bandages o Braces & Supports o Catheters o Contact Lens Solution/Supplies o Denture Adhesive o Diagnostic Tests & Monitors o Elastic Bandages & Wraps o First Aid Supplies* o Insulin & Diabetic Supplies o Ostomy Products o Reading Glasses o Wheelchairs, Walkers & Canes *those that do not contain ointment Eligible expenses may vary from employer to employer. In case of a conflict between your plan documents and the information in this material, the plan documents will govern. Please refer to your employer s Summary Plan Description ( SPD ) for more information about your covered benefits. This material is for informational purposes only. Information is believed to be accurate as of the production date; however, it is subject to change. 2013 PayFlex Systems USA, Inc. 69.03.462.1 (10/13) Page 33

The PayFlex Card, your account debit card Spending made simple Instant access to your money The PayFlex Card helps make it easier for you to spend the money in your tax-advantaged account. When you use the debit card, it uses the money in your account to pay for eligible expenses. Check with your employer to find out what expenses are eligible under your plan. Frequently asked questions How does the card work? Your PayFlex Card can be used to pay for eligible products and services under your plan. When you receive the PayFlex Card in the mail, call the number on the card to activate it and get your personal identification number (PIN). To use your card, simply swipe and select either debit or credit. Please note that some merchants may ask you to select debit. This means you ll need to enter your PIN to complete the transaction. If your spouse or dependent also has a PayFlex Card, they will use the same PIN you use. You can call Card Services for help if you forget your PIN or want to change your PIN. After you swipe the card, our system automatically checks to see if you have enough funds to pay for the expense. Where can I use the card? You can use your card at qualified merchants where MasterCard is accepted, and where merchants can process health care cards. This includes doctor and dental offices, hospitals, pharmacies and hearing and vision care centers. You can also use your card at some discount and grocery stores. * If you want to use your account funds for OTC drugs and medicine, you ll need a written prescription from your doctor. After you get the prescription, pay for the expense out of pocket. Then submit a claim to pay yourself back. You can't use the PayFlex Card. What can I pay for with my card? You can use the card to pay for eligible expenses allowed under your plan. These generally include: Deductibles, copays and coinsurance Prescriptions and certain over-the-counter (OTC) items* Dental and vision costs To view the list of common eligible expense items, visit your PayFlex member website. Note: Some cards might only be able to be used for specific expenses. Check your plan details to confirm before using your card. What if I don t use my card to pay for an expense? You can pay for an eligible expense with cash, check or a personal credit card. You can then submit a claim to pay yourself back. You can submit claims online or through the PayFlex Mobile app. You can also fill out a paper claims form and fax or mail it to PayFlex. Note: Remember to include supporting documentation when you submit your claim. 69.03.302.1 B (3/15) Page 34

Quick tips Spending made simple for the family If you re a new member, you ll automatically receive one card. You can order additional cards online for your spouse or dependent(s) at no cost. Save your receipts If you receive a Request for Documentation letter or see an alert message on your account, this means we need documentation for a card purchase. Access your account balance Log in to your PayFlex member website. You can view your available balance on My Dashboard. Check your card s expiration date Your card is valid for five years, as long as you re an active member. Before your card expires, you ll receive a new card in the mail. Replace lost or stolen cards Please call us right away at 1-888-879-9280 to report a lost or stolen card. Request for Documentation alerts and letters There may be times that we need documentation from you to verify that your card was used to pay for an eligible item or service. If this happens, we ll post an alert message online or send you a Request for Documentation letter. To help stay up to date on your card transactions, we encourage you to sign up for debit card notifications through e-mail, web alert or both. Log in to your PayFlex member website and click on My Settings. Then click on Manage Notifications and select the notifications you wish to receive. Be sure to sign up for the Debit Card Substantiation Notification. How to respond to a Request for Documentation alert or letter If we need more information on a debit card purchase, you have three options. 1. Send us the Explanation of Benefits (EOB) or itemized receipt for the card payment. You can upload your documentation to the PayFlex site, send through the PayFlex Mobile app, or fax or mail it to us. 2. Substitute another expense for the one in question. Upload, fax or mail* the EOB or itemized receipt for another eligible item or service incurred in the same plan year. (Note: This option is only available if you haven t been reimbursed for the item or service. And if you haven t already paid for it with your PayFlex Card.) 3. Pay back your account for the amount in question. Send a personal check or money order directly to PayFlex. Note: If you don t respond to the request, your card may be suspended until you either send in the requested documentation or pay back the account. *If you choose to fax or mail documentation, include a copy of your Request for Documentation letter. PayFlex Systems USA, Inc. This material is for informational purposes only and is not an offer of coverage. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. MasterCard is a registered trademark of MasterCard International Incorporated. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about PayFlex, go to www.payflex.com. PayFlex Mobile is a registered trademark of PayFlex Systems USA, Inc. 2015 PayFlex Systems USA, Inc. 69.03.302.1 B (3/15) Page 35

PayFlex Mobile Quick Reference Guide Don t go another day without our mobile app Get access to your PayFlex account with our free* PayFlex Mobile application. This app makes it easy for you to manage your account virtually 24/7. It s available for iphone and ipad mobile digital devices, as well as Android and BlackBerry smartphones. Getting started is easy 1. Create a username and password. If you already have a HealthHub username and password, go to step 2. If not, go to HealthHub.com. Click on Employee Account Login. Click on Register Now to get started. 2. From your mobile app store, download PayFlex Mobile. 3. To log in to the app, enter your username and password, then select Login. After you log in to the app, you ll see My Dashboard. This connects you to: Financial Center Benefits Center (if applicable) My HealthHub Resources Alerts Contact Us Note: Not all of the PayFlex Mobile functionality is available for BlackBerry smartphones. Menu layout, designs and screen displays may vary on your device. Using the mobile app features Financial Center You can view your account information and request reimbursement for your out-of-pocket expenses. View account information: To get started, select the account you wish to view. If you have a reimbursement account, you can: View all of your transactions in one list. Select Claims or Deposits to narrow your view. View the details of your transactions. Select the transaction you wish to view. View a summary of your account. On the Details page, select the account to view a summary. If you have a health savings account (HSA), you can: Use the Make a Deposit feature to contribute funds to your HSA. Use the Make a Withdrawal feature to request reimbursement for your out-of-pocket expenses. Use the Make a Payment feature to pay your health care provider directly for the amount you owe. View all of your transactions in one list. View the details of your transactions. Select the transaction you wish to view. View a summary of your account. On the Details page, select the account to view a summary. * Standard text messaging and other rates from your wireless carrier still apply. 00.03.625.1 (9/13) Page 36

Submit a claim for reimbursement This is available if you have a reimbursement account. This option does not apply to the HSA. To get reimbursed through your HSA, you must use the Make a Withdrawal feature. From the Financial Center, select File a Claim. Select your employer (if applicable) and your expense type. In the Expense Start Date field, enter the date of service or purchase. Enter the amount that you paid for the product or service. For a dependent care expense, enter the expense end date and your dependent s name. To attach a document, select the Add Photo image. Then select Review Claim. After you review your claim, select Submit. If you need to make a change, select Cancel. Select I Agree to submit your claim. Select Go Back to make a change. Don t have a phone with a camera? Complete the claim submission process online. Benefits Center If offered by your employer, this center features your benefit information and the contact details for your health plan and primary physician. You have to enter this information on HealthHub.com to view it on the app. If you want to add information or make changes, log in to HealthHub.com. From there, click on the Benefits Center tab. My HealthHub Resources You can view a list of common eligible expenses. You can also view any agreements and terms of use that we have sent to you. Select Expenses and choose the expense list you wish to view. Select Documents Center and select the document you wish to view. Alerts If you see an alert, select it to view more details. Here are two alerts you may see on the mobile app. Alert: Claims requiring substantiation You may see this if your employer offers the PayFlex Card, your account debit card. This red alert message will let you know if we need documentation for a debit card purchase. Note: This does not apply to HSAs. To take action, select Learn More. You can upload your documentation on the app. Select the Add Photo image. Note: This photo button will only appear on phones that have a camera or photo library. Take a photo of your documentation or choose the image from your photo library. Make sure your photo clearly shows the date of service, the amount of purchase, a description of the product or service, the name of the merchant or provider and, if applicable, the name of the patient. If the photo is not clear, select Cancel. If the photo is clear and readable, select Choose. Alert: Claims payments After you submit a claim, you ll see an alert message confirming the amount and when you can expect reimbursement. This will show after we process your claim and have approved it for payment. Simply select the alert to view the details. Note: This does not apply to HSAs. Contact Us You have a number of ways to contact us. Through the app, you can view our toll-free customer service number, fax number and mailing address; our customer service hours; and the member website. If you re having issues downloading the app, contact your smartphone carrier. Questions? Call us at 1-800-284-4885. Customer service representatives are available Monday Friday from 7 a.m. 7 p.m. CT and Saturday from 9 a.m. 2 p.m. CT. Apple, the Apple logo, iphone and ipad are trademarks of Apple Inc., registered in the U.S. and other countries. BlackBerry and related trademarks, names and logos are the property of Research In Motion Limited and are registered and/or used in the U.S. and countries around the world. Used under license from Research In Motion Limited. Android is a trademark of Google Inc. This material is for informational purposes only. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about PayFlex, go to HealthHub.com. 2013 PayFlex Systems USA, Inc. 00.03.625.1 (9/13) Page 37

HealthHub.com Quick Reference Guide Take advantage of all the online features and tools available to you. This guide will help you easily manage your account online. Get started To access and manage your account, go to HealthHub.com. Click on Employee Account Login. Enter your username and password. Click Login. If you are a new user, you ll have to register first. Click on Register Now. Enter your member ID (which could be your Social Security number or employer assigned number). Also enter your home ZIP code. You may have to enter an employer ID. Please call 1-800-284-4885 for this number. Click Register. Create a user name and password. Then select a security question and answer. Enter your e-mail address and click Confirm. View eligible expense items After you log in, the list of common eligible expense items is found in My HealthHub Resources under Planning Tools. View your account balance, deposits and payments Click on the Financial Center tab. From the drop-down menu, select the account you wish to view. To view all of your claims, select Claims. To view all of your payments and deposits, select Transactions. Account alerts On My Dashboard you can view your account alerts, if applicable. These messages can tell you the status of your card, claim information and if you need to provide documentation for card purchases. How to file a claim To get reimbursed for an out-of-pocket expense, log in to HealthHub.com. Under Quick Links, click on File a Claim. If prompted, select Pay Me. Enter your claim information. To add additional claims, select Add Another Claim. Once you enter in all of your claims, click Next. Confirm all expense details and click Next. To make changes, click Previous. Select Fax or Upload. To Fax, click on Create Coversheet. Print and sign the form. Fax it with your documentation to the number on the coversheet. When you sign the fax coversheet, you certify that your claim is for an eligible expense. To Upload, use the Browse button. Select your documentation from your computer. To add additional documents, click on Add Additional Document. Note: Each document must be uploaded in PDF format. Check the signature box to sign your claim and confirm your submission is for eligible expenses. Click Submit. 69.03.353.1 (7/13) Page 38

If offered by your employer, you can also use Pay Them to pay your health care or dependent care provider directly. After you log in to HealthHub.com, click on File a Claim, under Quick Links. Select Pay Them. Select your payee from the drop-down menu and click Next. To add a new payee, click on the + symbol. If you add a new payee, complete all the required fields. Click Save, then click Next. Enter your contact number, statement date and invoice number (if applicable); patient name; and any comments you may have. Click Next. Fill in your claim information and click Next. Verify that your claim information is correct. Click Next. Select Fax or Upload. To Fax, click on Create Coversheet. Print and sign the form. Fax it with your documentation to the number on the coversheet. When you sign the fax coversheet, you certify that your claim is for an eligible expense. To Upload, use the Browse button. Select your documentation from your computer. To add additional documents, click on Add Additional Document. Note: Each document must be uploaded in PDF format. Click Submit. Note: Be sure to sign up for the Explanation of Payment electronic notification through My Settings. This informs you when your claim has been processed. Order an additional PayFlex Card From My Dashboard, under Quick Links select Manage My Debit Card(s). If you would like to order an additional debit card for a dependent or spouse, select Order A Dependent Debit Card. Enter the first and last name of your dependent or spouse. Then click Submit. Your card will arrive within 15 business days. If your card is lost or stolen, call us immediately at 1-800-284-4885. Do not order another card online. Sign up for electronic account updates To help you stay up to date on your account, we encourage you to sign up to receive notifications through e-mail, on the web or both. From My Dashboard, select My Settings. Select Notifications/Email Address. Enter your e-mail address. Select the notification(s) you wish to receive. Then click Submit. For fast reimbursements, enroll in direct deposit On the left side of the screen, click on My Accounts and Services. Then click on Enroll in Direct Deposit. Select your employer (if applicable) and bank account type. Enter your account number, routing number and bank name. Click Next. Review your account information. If the information is correct, click Confirm. If you need to make a change, click Previous. Stay connected with PayFlex Mobile If offered by your employer, you can also access your account virtually 24/7 through the PayFlex Mobile application. Available from most smartphones, the FREE* PayFlex app lets you: View important account alerts View your account balance, deposits and payments Submit a claim for reimbursement View a list of common eligible expense items Questions? Visit HealthHub.com or contact customer service at 1-800-284-4885. Representatives are available Monday Friday, 7 a.m. 7 p.m. CT and Saturday, 9 a.m. 2 p.m. CT. *Standard text messaging and other rates from your wireless carrier still apply. This material is for informational purposes only and is not an offer of coverage. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about PayFlex, go to HealthHub.com. 2013 PayFlex Systems USA, Inc. 69.03.353.1 (7/13) Page 39