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AUTO FLEX DIRECT DEPOSIT Quick Easy Automatic Auto Flex Sign up for Auto Flex today and take advantage of hassle free Health Care Flexible Spending Account reimbursements No claims to file When you are enrolled in the employer s group health plan and have claims applied to your deductible coinsurance or co pay Benefit Management will automatically generate an eligible reimbursement from your Health Care FSA to reimburse you for those patient responsibility expenses Without ever filing a claim your FSA reimbursement will arrive soon after your medical or dental claim is final It s quick easy and provides automatic reimbursements of your FSA dollars Paper claims are still available at any time and for any eligible FSA expense Direct Deposit Take advantage of our direct deposit feature to obtain quick access to your reimbursement funds Sign up today with a Direct Deposit Authorization Form With direct deposit Benefit Management will deposit your Health Care or Dependent Care FSA reimbursements directly into your checking account You will receive an email notice to let you know when your funds will be deposited Can anyone sign up for Auto Flex Auto Flex is not available to everyone If you have other medical or dental insurance or other options that will reimburse you any portion of your out ofpocket expenses you cannot enroll in Auto Flex Can I stop Auto Flex at any time Yes You can change your election for Auto Flex at any time by completing a new Auto Flex Election Form and submitting the form to Human Resources Do I have to sign up for Auto Flex and Direct Deposit No You may elect one program independent of the other both programs at once or none at all Dependent Care FSA reimbursements are not eligible for Auto Flex

FSA with Rollover Dear Employee It s that time of year your annual opportunity to review your current benefit elections and choose the best health benefits for you and your family That means it s the perfect time to sign up for a healthcare Flexible Spending Account FSA a valuable benefit that helps you pay for health related out of pocket costs not covered by your insurance Real Savings Real Simple Flexible Spending Accounts are a great way to stretch your benefit dollars Enjoy significant tax savings with pre tax deductible contributions and tax free reimbursements used for qualified plan expenses Enjoy 24 7 access to your accounts using the secure Benefit Management Flex portal And with the 500 Rollover from one plan year to the next so you have greater flexibility and less stress Even with just a few hundred dollars of expenses you ll be surprised at how much you can save For example an average family of four in the U S can expect to pay close to 3 500 in out of pocket medical expenses An individual contribution to an FSA is a maximum of 2 650 per plan year so if two wage earners in the family each set aside 1 750 in a healthcare FSA that s a tax savings of nearly 1000 for the family 2 Out of Pocket Expenses 1 Annual Average Taxes Saved 27 Tax Bracket Physician 1 110 299 Inpatient Hospital 1 115 301 Pharmacy 555 150 Outpatient Hospital 560 151 Other 130 35 Total 3470 936 According to the U S Internal Revenue Service guidelines each employee can contribute a maximum of 2650 per plan year in 2018 2 Tax savings is dependent upon your annual income and tax bracket Example for demonstration purposes only 2016 All Rights Reserved Evolution1 Inc a WEX Company 1114

Use it or Roll It Over And now up to 500 of your unused healthcare Flexible Spending Account balance can be carried over into the next plan year instead of you losing it making enrollment in an FSA much less risky This gives you more flexibility to spend your FSA money when you need it You can use it for necessary out of pocket healthcare expenses rather than feeling pressured to engage in last minute and potentially unnecessary spending at the end of the year or grace period Relax Your FSA now offers more flexibility Quit worrying about having to precisely predict your out of pocket medical expenses a whole year in advance The new rollover feature assures that any unused balance of up to 500 will still be there for you in the next plan year As you plan for enrollment spend some time deciding how much you want to contribute to your account s You will want to spend some time estimating your anticipated eligible medical and dependent care expenses for the new Plan year but know that you don t have to worry about losing unused funds up to 500 Real savings just got Simpler Sign up today and let the savings begin Look for more information about FSAs during open enrollment 2016 All Rights Reserved Evolution1 Inc a WEX Company 1114

Flexible Spending AccountReal Savings Real Simple Using a Flexible Spending Account FSA is great way to stretch your benefit dollars You use before tax dollars in your FSA to reimburse yourself for eligible out of pocket medical and dependent care expenses That means you can enjoy tax savings and increased take home pay all with the convenience of a prepaid benefits card Plus you can rollover 500 from one year to the next reducing your risk of losing dollars at the end of the plan year WHAT IS AN FSA WITH AN FSA YOU CAN An FSA is a great way to pay for expenses with pre tax dollars Enjoy significant tax savings with pre tax deductible contributions and tax free reimbursements for qualified plan expenses Quickly and easily access funds using the prepaid benefits card at point of sale or request to have funds directly deposited to your bank account via online or mobile app With an FSA you elect to have your annual contribution up to the 2 650 limit set by the IRS deducted from your paycheck each pay period in equal installments throughout the year until you reach the yearly maximum you have specified The amount of your pay that goes into an FSA will not count as taxable income so you will have immediate tax savings FSA dollars can be used during the plan year to pay for qualified expenses and services A Healthcare FSA allows reimbursement of qualifying out of pocket medical expenses A Dependent Care FSA allows reimbursement of dependent care expenses such as daycare incurred by eligible dependents File claims easily online when required and let the system determine approval based on eligibility and availability of funds With all FSA account types you ll receive access to a secure easy to use web portal where you can track your account balance view your claims history and submit requests for reimbursements Use it or Roll It Over And now up to 500 of your unused healthcare Flexible Spending Account balance can be carried over into the next plan year instead of you losing it making enrollment in an FSA much less risky This gives you more flexibility to spend your FSA money when you need it You can use it for necessary out of pocket healthcare expenses rather than feeling pressured to engage in last minute and potentially unnecessary spending at the end of the year 2016 All Rights Reserved Evolution1 Inc a WEX Company 1114 Enjoy secure access to accounts using a convenient Consumer Portal available 24 7 365 Manage your FSA on the go with an easy to use mobile app Stay up to date on balances and action required with automated email alert and convenient portal and mobile home page messages Get one click answers to benefits questions

IS AN FSA RIGHT FOR ME An FSA is a great way to pay for expenses with pre tax dollars A Healthcare FSA could save you money if you or your dependents Have out of pocket expenses like co pays coinsurance or deductibles for health prescription dental or vision plans Have a health condition that requires the purchase of prescription medications on an ongoing basis Wear glasses or contact lenses or are planning LASIK surgery Need orthodontia care such as braces or have dental expenses not covered by your insurance A Dependent Care FSA provides pre tax reimbursement of out of pocket expenses related to dependent care This benefit may make sense if you and your spouse if married are working or in school and Your dependent children under age 13 attend daycare after school care or summer day camp You provide care for a person of any age whom you claim as a dependent on your federal income tax return and who is mentally or physically incapable of caring for himself or herself PLAN AHEAD Before you enroll you must first decide how much you want to contribute to your account s You will want to spend some time estimating your anticipated eligible medical and dependent care expenses for the new Plan year but know that you don t have to worry about losing unused funds up to 500 Throughout the year you ll likely find yourself with expenses for yourself and your family that insurance won t cover By taking advantage of an FSA you can actually reduce your taxable income and reduce your out of pocket expenses when you use your FSA to pay for the things you d purchase anyway The amount you save in taxes with a Flexible Spending Account will vary depending on the amount you set aside in the account your annual earnings whether or not you pay Social Security taxes the number of exemptions and deductions you claim on your tax return your tax bracket and your state and local tax regulations Check with your tax advisor for information on how participation will affect your tax savings 2016 All Rights Reserved Evolution1 Inc a WEX Company 1114 Above With the convenience of a mobile device you can see your available balance anywhere anytime as well as file claims and upload receipts

Frequently Asked Questions about your FSA with Rollover 1 What is a Flexible Spending Account FSA An FSA is an employer sponsored plan that allows to deduct dollars from your paycheck and deposit them into a special account that s protected from taxes FSA accounts are exempt from federal taxes Social Security FICA taxes and in most cases state income taxes The money in an FSA can be used for eligible health and or dependent care expenses that are incurred while you are participating in the plan 2 When does my FSA become effective Your FSA becomes effective on the date you enroll Unlike other plans an FSA does not start on your hire date Contributions to your account begin as soon as administratively possible after you enroll 3 How do I participate in an FSA To participate you must enroll within the timeframe required by your employer or elect to participate during annual Open Enrollment If you have a life event change for example birth or adoption of a child then you may be able to enroll without waiting for annual Open Enrollment if you enroll within 31 days of the change 4 Who can put money in my FSA You and your employer although employers rarely contribute to employees FSAs 5 What does it mean to incur expenses The IRS considers expenses to be incurred at the time you receive medical care or dependent care not when you are formally billed or actually pay for services Only eligible expenses you incur within the plan year including any employer allowed grace period are eligible for reimbursement 6 Who qualifies as an eligible dependent An eligible dependent is any dependent for which an employee pays a provider to care for him her while they are at work or looking for work The dependent must be under the age of 13 or incapable of taking care of themselves and live in the employee s home for more than half of the year 7 How often can I request reimbursements Reimbursements can be requested as often as qualified expense are incurred Your plan allows for automatic claims processing through your flex account Any patient responsibility amount applied on your medical claims processed through your employer s major medical plan will automatically transfer to your flex account and be paid directly to you Expenses must be incurred during the plan year and the reimbursement must be requested before the end of the run out period 8 What happens if I have money remaining in my account at the end of the year You are now able to roll over remaining funds into your next plan year up to 500 00 This rollover means enrollment in an FSA is much less risky This gives you more flexibility to spend your FSA money when you need it You can use it for necessary out of pocket healthcare expenses rather than feeling pressured to engage in last minute and potentially unnecessary spending at the end of the year or grace period Copyright 2016 Evolution1 Inc a WEX Company 1114

9 Can I change my election or stop contributing money to my FSA at any time during the plan year Federal regulations state that once you have enrolled in an FSA you cannot change your election amount unless you have a qualifying life event Your employer can give you a list of permitted change events 10 How much will I really save in taxes by contributing to an FSA Generally contributions you make to your FSA are not subject to federal or social security taxes In most instances there are no state taxes taken out either The amount you may save depends upon The amount you put into your FSA The tax percentage you would normally pay on that money tax bracket Let s say you want 2 000 taken out of your paycheck this year to put into your FSA The money you direct to your FSA is taken out of your check before taxes are taken out That reduces your taxable income by 2 000 Let s say you normally pay 30 percent in federal social security and state taxes on your income In this example you would enjoy a tax savings of 30 percent of the 2 000 In other words you could get a 600 tax savings on the 2 000 you directed to your FSA Plus the new rollover feature assures that any unused balance of up to 500 will still be there for you in the next plan year 11 What type of flexible spending plans are there Health Care FSA Covers medical prescription dental and vision expenses Dependent Care FSA Covers dependent care expenses including daycare nursery school and day camp for children and services for adult dependents who cannot care for themselves Copyright 2016 Evolution1 Inc a WEX Company 1114

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 that qualify as federal income tax deductions under Section 213 d of the Internal Revenue Code IRC Health Care FSA dollars can be used to reimburse you for medical and dental expenses incurred by you your spouse or eligible dependents children siblings parents and other dependents which are defined in your Plan Documents HRA dollars can only be used to pay for eligible medical expenses incurred by employees and their dependents enrolled in the HRA IMPORTANT Not all expenses are eligible under all plans An employer may limit which expenses are allowable under their Health Care FSA or HRA plan If you are unsure of what your Health Care FSA and or HRA dollars may be used for please contact your Plan Administrator The following is a list of expenses currently eligible and not eligible by the Internal Revenue Service IRS as deductible medical expenses This list is not necessarily inclusive or exclusive and may be subject to change based on regulations IRS revenue rulings and case law It is solely based on our current interpretation of IRC Section 213 d and is not intended to be legal advice 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 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 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 2014 All Rights Reserved Evolution1 Inc a WEX Company 1114

Please Note Currently 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 This list is not meant to be all inclusive Ineligible Expenses Contact Lens or Eyeglass Insurance Cosmetic Surgery Procedures Electrolysis Marriage or Career Counseling Swimming Lessons Personal Trainers Sunscreen spf less than 30 Please Note Currently the IRS does not allow Over the Counter OTC medicines or drugs to be purchased with Health Care FSA or HRA funds unless accompanied by a prescription and the prescription is filled by a pharmacist 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 As of January 1 2011 eligible over the counter OTC products that are medicines or drugs e g acne treatments allergy and cold medicines antacids etc will only be eligible for reimbursement from your Health Care FSA with a physician s prescription that includes his or her address and license number as stated in IRS Notice 2010 59 The only exception is insulin which will not require a prescription OTC items that are not medicines or drugs remain eligible for purchase with FSAs and HRAs 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 For additional information please contact your Plan Administrator and or tax advisor 2014 All Rights Reserved Evolution1 Inc a WEX Company 1114 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

Section 125 Claim Reimbursement Form Section 1 General Account Information Employee Last Name First Name Employee Social Security Number MI State ZIP Code Mailing Address City Phone Name of Employer Section 2 Claim Filing Instructions Submit the following for expense reimbursement 1 Completed Section 125 Claim Reimbursement Form 2 Copy of your service claim receipt sufficient information for proof of eligible expense is required An Explanation of Benefits from an insurance company may qualify Keep a copy for your records 3 Physician s prescription or statement of medical necessity for any over the counter medication KEEP YOUR ORIGINAL RECEIPT the IRS may require proof of expenses during an audit MAILING INSTRUCTIONS Mail this submission Benefit Management LLC Attn FSA Claims Dept P O Box 1090 Great Bend KS 67530 P 888 922 4622 F 620 792 7053 Section 3 Claim Detail Information HEALTH CARE EXPENSES Date s of Service Claimant Type of Service Reimbursement Amount DEPENDENT CARE EXPENSES Date s of Service Provider s Signature required if receipt is not provided Reimbursement Amount Provider Tax ID or SSN required Provider s Address Age of Dependent s at Time of Service Section 4 Employee Authorization This is to certify that my statements on this Reimbursement Form are complete and true I understand that I am solely responsible for the validity of claims submitted to my Section 125 Flexible Spending account I am claiming reimbursement for eligible expenses incurred during the applicable plan year for myself spouse and or dependents The Medical Expenses I am submitting have not been reimbursed or are not reimbursable under any other health plan coverage and if reimbursed from the Health Flexible Spending Account such amount will not be claimed as a tax deduction Participant s Signature FORM NUMBER Date

Direct Deposit Authorization Form Fax or mail the completed authorization form with a voided check from your checking account or a deposit slip from your savings account to Benefit Management LLC Attn FSA Claims Dept PO Box 1090 Great Bend KS 67530 620 792 7053 fax Last Name Address City Employer Name First Name State Zip Code Email Address This information is required Notification of processing and fund transactions will be sent via email _____________________________________ Social Security Number Work Phone Effective Date _____ ____ ______ ______ _______ ___________ ____ ____ ____ Month Day Year New Request Change Request Cancel Request Name of Financial Institution __________________________________________ Checking Account Savings Account Account Number________________________ Routing Number________________________ Account Ownership Individual Joint Terms and conditions 1 2 3 4 5 6 7 Your financial institution must be a member of an Automated Clearing House in order for you to participate in the Direct Deposit Program You must complete this authorization form in its entirety This completed form and a voided check from the account to be deposited is required to initiate direct deposit banking Please allow up to 4 weeks to process this request Claims submitted during the implementation period will be processed and sent to the account on record in the manner formerly issued If an electronic transfer cannot be deposited to your account Benefit Management will investigate the cause and attempt corrective action If Benefit Management cannot successfully complete a deposit a substitute check will be mailed to you This may cause you a delay in receiving funds Pending resolution of the electronic transfer problem you will continue to receive reimbursement checks in the mail Reinstatement in the Direct Deposit Program will be determined on a case by case basis If a direct deposit is made in error Benefit Management reserves the right to reverse such deposit It is your responsibility to notify Benefit Management immediately of any changes in your account You may cancel your participation in the Direct Deposit program at any time by completing this form and indicating the action is to cancel Benefit Management reserves the right to cancel your participation in the Direct Deposit program automatically Your financial institution may also cancel this agreement I certify that I have read and understand the terms of this agreement I authorize Benefit Management to initiate credit entries to the account indicated above for the purpose of reimbursement from my flexible spending account and or health reimbursement arrangement X Date Employee Accountholder Signature RA02_DDAF 1608 Attach a voided check from the account to be deposited