Things to do no later than November, 23, 2011 Documents/2012_OE_package_Flexco.pdf · Things to do no later than November, 23, 2011: Complete BCBS enrollment form only if you are

Things to do no later than November, 23, 2011:

� Complete BCBS enrollment form only if you are adding/dropping coverage for yourself or dependent(s). Note: If retiring in 2012 and eligible for retiree health insurance, you (and spouse) must be insured by Flexco’s plan prior to retirement to be eligible for retiree health plan.

� Complete a Guardian enrollment form only if you are adding/dropping coverage for yourself or dependent(s)

To be green, the above enrollment forms are not in this packet, but can be found on our benefits website, www.hrconnection.com User name: flexco Password: Cobenefits1

� Complete Discovery Flexible Spending form regardless if you are enrolling or waiving enrollment in this plan

� Return the above form(s) to Cyndi Baltes in HR

� Inform covered family members of any changes to coverage.

All enrollment / Flex Spending form(s) are due to Cyndi Baltes by Wednesday, November 23

Participating Provider Option PPO 01/01/12

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 2

Flexib le S tee l Lac ing Company P89982

B E N E F I T H I G H L I G H T S P P O N e t w o r k This provides only highlights of the benefit plan. After enrollment, members will receive a Certificate that more fully describes the terms of coverage.

P r o g r a m B a s i c s P P O (In-Network)

N o n - P P O (Out-of-Network)

Lifetime Benefit Maximum

Per individual Unlimited Individual Coverage Deductible Program deductible does not apply to services that have a copayment. $250 $500 Family Coverage Deductible The family deductible maximum is equal to three individual deductibles. 3x Individual

Individual Coverage Out-of-Pocket Expense (OPX) Limit The amount of money that any individual will have to pay toward covered health care expenses during any one

calendar year. The following items will not be applied to the out-of-pocket expense limit: Copayments Reductions in benefits due to non-compliance with utilization management program requirements Charges that exceed the eligible charge or the Schedule of Maximum Allowances (SMA) Services that are asterisked below (*)

$1,500 $4,000

Family Coverage Out-of-Pocket Expense (OPX) Limit $4,000 $9,000 Prescription Drug Card (Retail and Mail Service) Please refer to the Outpatient Prescription Drug Highlights Sheet for the covered benefits.

P h y s i c i a n S e r v i c e s

Physician Office Visits One copayment per day when you receive services from a Family Practice, Internal Medicine, OB/GYN, or

Pediatrician. Surgeries, therapies and certain diagnostic procedures performed in a physician’s office may be subject to the deductible and/or coinsurance, including mental health and substance abuse services.

$20 copay, then 100%

60% after deductible

One copayment per day when you receive services from a specialist. Surgeries, therapies and certain diagnostic procedures performed in a physician’s office may be subject to the deductible and/or coinsurance.



Preventive Care Routine annual physicals, well-baby exam, immunizations, and other preventive health services as determined

by the USPSTF. 100% 60% after deductible

Maternity Services Copayment applies to first prenatal visit (per pregnancy). All other maternity physician covered services are

paid the same as Medical / Surgical Services. $20 copay,

then 100% 60% after deductible

Medical / Surgical Services Coverage for surgical procedures, inpatient visits, therapies, allergy injections or treatments, and certain

diagnostic procedures as well as other physician services. 90% after deductible 60% after deductible

H o s p i t a l S e r v i c e s

Hospital Admission Deductible Per admission, per individual $0 $500 Inpatient Hospital Services Coverage includes services received in a hospital, skilled nursing facility, coordinated home care and hospice,

including mental health and substance abuse services. Room allowances based on the hospital’s most common semi-private room rates.

90% after deductible 60% after deductible

Outpatient Hospital Services Coverage for services includes, but is not limited to outpatient or ambulatory surgical procedures, x-ray, lab

tests, chemotherapy, radiation therapy, renal dialysis, and mammograms performed in a hospital or ambulatory surgical center, including mental health and substance abuse services. Routine mammograms performed in an in-network outpatient hospital setting are payable at 100%, no deductible will apply.

90% after deductible $250 copay then 60% after deductible

Outpatient Emergency Care (Accident or Illness) The copayment applies to both in- and out-of-network emergency room visits. The copayment is waived if the

member is admitted to the hospital. $150 copay,

then 100%

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PPO 1



B E N E F I T H I G H L I G H T S P P O N e t w o r k

A d d i t i o n a l S e r v i c e s

Muscle Manipulation Services* Coverage for spinal and muscle manipulation services provided by a physician or chiropractor. Related office

visits are paid the same as other Physician Office Visits. 24 visits maximum per benefit period.

$35 copay then 100% 60% after deductible

Therapy Services – Speech, Occupational and Physical Coverage for services provided by a physician or therapist, with out Office visit. 90% after deductible 60% after deductible Temporomandibular Joint (TMJ) Dysfunction and Related Disorders 90% after deductible 60% after deductible Other Covered Services Private duty nursing 10 visits max per month Ambulance services

Naprapathic services* - $3,000 maximum per calendar year Medical supplies Blood and blood components

See paragraph below regarding Schedule of Maximum Allowances (SMA).


* Does not apply to any out-of-pocket limits

Durable Medical Equipment (DME) is a covered benefit. Please refer to Certificate for details.

Optometrists, Orthotic, Prosthetic, Pedorthists, Registered Surgical Assistants, Registered Nurse First Assistants and Registered Surgical Technologists are covered providers. Please refer to Certificate for details.

Discounts on Eye Exams, Prescription Lenses and Eyewear Members can present their ID cards to receive discounts on eye exams, prescription lenses and eyewear. To locate participating vision providers, log into Blue Access® for Members (BAM) at www.bcbsil.com/member and click on the BlueExtras Discount Program link.

Blue Care Connection (BCC) When members receive covered inpatient hospital services, outpatient mental health and substance abuse services (MHSA), coordinated home care, skilled nursing facility or private duty nursing from a participating provider, the member will be responsible for contacting either the BCC or MHSA preauthorization line, as applicable. You must call one day prior to any hospital admission and/or outpatient MH/SA service or within 2 business days after an emergency medical or maternity admission. Failure to contact the applicable preauthorization line will result in benefits being reduced by $250.00 (Please refer to your benefit booklet for information regarding benefit reductions based on failure to contact the applicable preauthorization line). Note: Outpatient MHSA preauthorization is effective for services on or after January 1, 2011 or upon your group plan renewal date in 2011 and thereafter.

Schedule of Maximum Allowances (SMA) The Schedule of Maximum Allowances (SMA) is not the same as a Usual and Customary fee (U&C). Blue Cross and Blue Shield of Illinois’ SMA is the maximum allowable charge for professional services, including but not limited to those listed under Medical/Surgical and Other Covered Services above. The SMA is the amount that professional PPO providers have agreed to accept as payment in full. When members use PPO providers, they avoid any balance billing other than applicable deductible, coinsurance and/or copayment. “Please refer to your certificate booklet for the definition of Eligible Charge and Maximum Allowance regarding Providers who do not participate in the PPO Network.".

To Locate a Participating Provider: Visit our Web site at www.bcbsil.com/providers and use our Provider Finder® tool.

In addition, benefits for covered individuals who live outside Illinois will meet all extraterritorial requirements of those states, if any, according to the group’s funding arrangements.

Prescription Drug Card 01/01/2012



B E N E F I T H I G H L I G H T S

P r o g r a m B a s i c s P a y m e n t O p t i o n s (Generic / Formulary Brand /

Non-Formulary Brand)

Retail

Copayments are for up to a 34-day supply at a contracting retail pharmacy, including diabetic supplies: blood glucose test strips, diagnostic agents used with urine testing, glucagon.

$3 / $25 / $45

Mail Service

Maintenance medications are available for up to a 90-day supply and are subject to the appropriate copayment amount, including diabetic supplies: blood glucose test strips, diagnostic agents used with urine testing, glucagon.

$6 / $50/ $90

Contraceptives

Available at retail and mail service at the appropriate copayment level based on drug classification.

As indicated above

Self-Injectibles

Available at retail and mail service at the appropriate copayment level. As indicated above

*effective 1/1/10, members with a BCBSIL drug card will have lancets pay at a $0 copay

Reimbursement for non-contracting pharmacies Benefits at a non-contracting pharmacy are covered at 75% of the amount that would have been paid at a contracting pharmacy minus the appropriate copayment amount. Prior Authorization and Step Therapy Program Requirements Your physician may be required to obtain authorization from BCBSIL in order to receive benefits for certain drugs that have a potential for misuse. Examples of these medications include: rheumatoid arthritis, growth hormone, hepatitis C, and anabolic steroids. In the event prior authorization is not obtained, you will be responsible for the first $1,000 or 50% of the Eligible Charge, whichever is less. If you are required to receive prior authorization for certain medications under the step therapy program, you need to first try a proven, cost effective medication before progressing to a more costly treatment, if necessary. After a member has a prescription history for a lower-cost alternative medication, coverage will automatically be provided for a more costly medication included in the step therapy program, if the physician and member determine that it is necessary for the member to try a drug included in the program. As an alternative to receiving prior authorization for a drug included in the step therapy program, or paying the entire cost of the drug out-of-pocket, a member along with his/her physician may select another drug, which is not part of the program. Prescription drugs categories are added to the program and are subject to change periodically. To verify which drugs are included in your prescription drug benefit program, contact the Pharmacy Program customer service number, which is located on the back of your ID card. You can also visit the BCBSIL Web site at www.bcbsil.com and log on to Blue Access® for Members to find additional information. What is the Blue Cross and Blue Shield of Illinois formulary? The BCBSIL formulary is a regularly updated list of preferred drugs determined by our Pharmacy and therapeutic Committee, a national panel comprised of individuals who hold a medical or pharmacy degree who evaluate U.S. Food and Drug Administration (FDA)-approved drugs based on comparative clinical standards, including efficacy, safety, uniqueness and cost-effectiveness. The formulary includes all generic drugs and select group of brand drugs. The BCBSIL formulary is “open,” meaning that benefits are payable for drugs that are not on the formulary, but are subject to the highest copayment level. How can I find out if a drug is on the formulary, and if it is a generic or a brand name drug? As part of the enrollment literature, members may receive a list of some of the most commonly prescribed formulary drugs. If a particular drug does not appear on the list, members can:

Refer to the pocket edition of the BCBSIL formulary. Visit the BCBSIL Web site at www.bcbsil.com. Discuss the most appropriate drug therapy with their physician or pharmacist. Using generic drugs whenever possible will help save money.

How can I find a contracting pharmacy? Visit our Web site at www.bcbsil.com to find a contracting pharmacy. Rev. 07 / 2010


PPO 2



B E N E F I T H I G H L I G H T S P P O N e t w o r k This provides only highlights of the benefit plan. After enrollment, members will receive a Certificate that more fully describes the terms of coverage.

P r o g r a m B a s i c s P P O (In-Network)

N o n - P P O (Out-of-Network)

Lifetime Benefit Maximum

Per individual Unlimited Individual Coverage Deductible Program deductible does not apply to services that have a copayment. $750 $1,500 Family Coverage Deductible The family deductible maximum is equal to three individual deductibles. 3x Individual

Individual Coverage Out-of-Pocket Expense (OPX) Limit The amount of money that any individual will have to pay toward covered health care expenses during any one

calendar year. The following items will not be applied to the out-of-pocket expense limit: Copayments Reductions in benefits due to non-compliance with utilization management program requirements Charges that exceed the eligible charge or the Schedule of Maximum Allowances (SMA) Services that are asterisked below (*)

$2,000 $5,000

Family Coverage Out-of-Pocket Expense (OPX) Limit $6,000 $15,000 Prescription Drug Card (Retail and Mail Service) Please refer to the Outpatient Prescription Drug Highlights Sheet for the covered benefits.

P h y s i c i a n S e r v i c e s

Physician Office Visits One copayment per day when you receive services from a Family Practice, Internal Medicine, OB/GYN, or

Pediatrician. Surgeries, therapies and certain diagnostic procedures performed in a physician’s office may be subject to the deductible and/or coinsurance, including mental health and substance abuse services.



One copayment per day when you receive services from a specialist. Surgeries, therapies and certain diagnostic procedures performed in a physician’s office may be subject to the deductible and/or coinsurance.



Preventive Care Routine annual physicals, well-baby exam, immunizations, and other preventive health services as determined

by the USPSTF. 100% 50% after deductible

Maternity Services Copayment applies to first prenatal visit (per pregnancy). All other maternity physician covered services are

paid the same as Medical / Surgical Services. $25 copay,

then 100% 50% after deductible

Medical / Surgical Services Coverage for surgical procedures, inpatient visits, therapies, allergy injections or treatments, and certain

diagnostic procedures as well as other physician services. 80% after deductible 50% after deductible

H o s p i t a l S e r v i c e s

Hospital Admission Deductible Per admission, per individual $0 $500 Inpatient Hospital Services Coverage includes services received in a hospital, skilled nursing facility, coordinated home care and hospice,

including mental health and substance abuse services. Room allowances based on the hospital’s most common semi-private room rates.

80% after deductible 50% after deductible

Outpatient Hospital Services Coverage for services includes, but is not limited to outpatient or ambulatory surgical procedures, x-ray, lab

tests, chemotherapy, radiation therapy, renal dialysis, and mammograms performed in a hospital or ambulatory surgical center, including mental health and substance abuse services. Routine mammograms performed in an in-network outpatient hospital setting are payable at 100%, no deductible will apply.

80% after deductible $250 copay then 50% after deductible

Outpatient Emergency Care (Accident or Illness) The copayment applies to both in- and out-of-network emergency room visits. The copayment is waived if the

member is admitted to the hospital. $150 copay,

then 100%


PPO 2


B E N E F I T H I G H L I G H T S P P O N e t w o r k

A d d i t i o n a l S e r v i c e s

Muscle Manipulation Services* Coverage for spinal and muscle manipulation services provided by a physician or chiropractor. Related office

visits are paid the same as other Physician Office Visits. 24 visits maximum per benefit period.

$40 copay then 100% 50% after deductible

Therapy Services – Speech, Occupational and Physical Coverage for services provided by a physician or therapist. 80% after deductible 50% after deductible Temporomandibular Joint (TMJ) Dysfunction and Related Disorders 80% after deductible 50% after deductible Other Covered Services Private duty nursing 10 visits max per month Ambulance services

Naprapathic services* - $3,000 maximum per calendar year Medical supplies Blood and blood components

See paragraph below regarding Schedule of Maximum Allowances (SMA).


* Does not apply to any out-of-pocket limits

Durable Medical Equipment (DME) is a covered benefit. Please refer to Certificate for details.

Optometrists, Orthotic, Prosthetic, Pedorthists, Registered Surgical Assistants, Registered Nurse First Assistants and Registered Surgical Technologists are covered providers. Please refer to Certificate for details.

Discounts on Eye Exams, Prescription Lenses and Eyewear Members can present their ID cards to receive discounts on eye exams, prescription lenses and eyewear. To locate participating vision providers, log into Blue Access® for Members (BAM) at www.bcbsil.com/member and click on the BlueExtras Discount Program link.

Blue Care Connection (BCC) When members receive covered inpatient hospital services, outpatient mental health and substance abuse services (MHSA), coordinated home care, skilled nursing facility or private duty nursing from a participating provider, the member will be responsible for contacting either the BCC or MHSA preauthorization line, as applicable. You must call one day prior to any hospital admission and/or outpatient MH/SA service or within 2 business days after an emergency medical or maternity admission. Failure to contact the applicable preauthorization line will result in benefits being reduced by $250.00 (Please refer to your benefit booklet for information regarding benefit reductions based on failure to contact the applicable preauthorization line). Note: Outpatient MHSA preauthorization is effective for services on or after January 1, 2011 or upon your group plan renewal date in 2011 and thereafter.

Schedule of Maximum Allowances (SMA) The Schedule of Maximum Allowances (SMA) is not the same as a Usual and Customary fee (U&C). Blue Cross and Blue Shield of Illinois’ SMA is the maximum allowable charge for professional services, including but not limited to those listed under Medical/Surgical and Other Covered Services above. The SMA is the amount that professional PPO providers have agreed to accept as payment in full. When members use PPO providers, they avoid any balance billing other than applicable deductible, coinsurance and/or copayment. “Please refer to your certificate booklet for the definition of Eligible Charge and Maximum Allowance regarding Providers who do not participate in the PPO Network.".

To Locate a Participating Provider: Visit our Web site at www.bcbsil.com/providers and use our Provider Finder® tool.

In addition, benefits for covered individuals who live outside Illinois will meet all extraterritorial requirements of those states, if any, according to the group’s funding arrangements.

Prescription Drug Card 01/01/2012



B E N E F I T H I G H L I G H T S

P r o g r a m B a s i c s P a y m e n t O p t i o n s (Generic / Formulary Brand /

Non-Formulary Brand)

Retail

Copayments are for up to a 34-day supply at a contracting retail pharmacy, including diabetic supplies: blood glucose test strips, diagnostic agents used with urine testing, glucagon.

$3 / $30 / $60

Mail Service

Maintenance medications are available for up to a 90-day supply and are subject to the appropriate copayment amount, including diabetic supplies: blood glucose test strips, diagnostic agents used with urine testing, glucagon.

$6 / 60 / $120

Contraceptives

Available at retail and mail service at the appropriate copayment level based on drug classification.

As indicated above

Self-Injectibles

Available at retail and mail service at the appropriate copayment level. As indicated above

*effective 1/1/10, members with a BCBSIL drug card will have lancets pay at a $0 copay

Reimbursement for non-contracting pharmacies Benefits at a non-contracting pharmacy are covered at 75% of the amount that would have been paid at a contracting pharmacy minus the appropriate copayment amount. Prior Authorization and Step Therapy Program Requirements Your physician may be required to obtain authorization from BCBSIL in order to receive benefits for certain drugs that have a potential for misuse. Examples of these medications include: rheumatoid arthritis, growth hormone, hepatitis C, and anabolic steroids. In the event prior authorization is not obtained, you will be responsible for the first $1,000 or 50% of the Eligible Charge, whichever is less. If you are required to receive prior authorization for certain medications under the step therapy program, you need to first try a proven, cost effective medication before progressing to a more costly treatment, if necessary. After a member has a prescription history for a lower-cost alternative medication, coverage will automatically be provided for a more costly medication included in the step therapy program, if the physician and member determine that it is necessary for the member to try a drug included in the program. As an alternative to receiving prior authorization for a drug included in the step therapy program, or paying the entire cost of the drug out-of-pocket, a member along with his/her physician may select another drug, which is not part of the program. Prescription drugs categories are added to the program and are subject to change periodically. To verify which drugs are included in your prescription drug benefit program, contact the Pharmacy Program customer service number, which is located on the back of your ID card. You can also visit the BCBSIL Web site at www.bcbsil.com and log on to Blue Access® for Members to find additional information. What is the Blue Cross and Blue Shield of Illinois formulary? The BCBSIL formulary is a regularly updated list of preferred drugs determined by our Pharmacy and therapeutic Committee, a national panel comprised of individuals who hold a medical or pharmacy degree who evaluate U.S. Food and Drug Administration (FDA)-approved drugs based on comparative clinical standards, including efficacy, safety, uniqueness and cost-effectiveness. The formulary includes all generic drugs and select group of brand drugs. The BCBSIL formulary is “open,” meaning that benefits are payable for drugs that are not on the formulary, but are subject to the highest copayment level. How can I find out if a drug is on the formulary, and if it is a generic or a brand name drug? As part of the enrollment literature, members may receive a list of some of the most commonly prescribed formulary drugs. If a particular drug does not appear on the list, members can:

Refer to the pocket edition of the BCBSIL formulary. Visit the BCBSIL Web site at www.bcbsil.com. Discuss the most appropriate drug therapy with their physician or pharmacist. Using generic drugs whenever possible will help save money.

How can I find a contracting pharmacy? Visit our Web site at www.bcbsil.com to find a contracting pharmacy. Rev. 07 / 2010

Step Therapy Program

Blue Cross and Blue Shield of Illinois is working to fi nd ways to manage the rising cost

of prescription drugs. Your benefi t plan uses tools, such as step therapy, that can help

control costs for everyone.

What is step therapy?

The step therapy program encourages safe and cost-effective medication use. Under this program, a “step” approach is required to receive coverage for certain high-cost medications. This means that to receive coverage you may need to fi rst try a proven, cost-effective medication before using a more costly treatment, if needed. Remember, treatment decisions are always between you and your doctor.

Don’t more expensive drugswork better?

Not necessarily. A higher cost does not automatically mean a drug is better. For example, a brand drug may have a less-expensive generic or brand alternative that might be an option for you. Generic and brand drugs must meet the same standards set by the U.S. Food and Drug Administration for safety and effectiveness. Work with your doctor to determine which medication options are best for you.

Work with your doctor to

determine which medication

options are best for you.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association

20942.0910

How does the program work?

The step therapy program requires that you have a prescription history for a “fi rst-line” medication before your benefi t plan will cover a “second-line” drug.

o A fi rst-line drug is recognized as safe andeffective in treating a specifi c medicalcondition, as well as being cost-effective.

o A second-line drug is a less-preferred or sometimes more costly treatment option.

Step 1When possible, your doctor should prescribe a fi rst-line medication appropriate foryour condition.

Step 2If your doctor determinesthat a fi rst-line drug is not appropriate for you or is not effective for you, your prescription drug benefi t will cover a second-line drug when certain conditions are met.

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The step therapy

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Drug Categories Which May Be Included

in the Step Therapy Program*

Cholesterol

Depression

Diabetes (GLP-1 Receptor Agonists)

Epilepsy

Gastroesophageal Refl ux Disease (Proton Pump

Inhibitors)

Glucose Test Strips

Insomnia

Migraine

Non-sedating Antihistamines

Osteoporosis

Pain Relief (COX-2 Inhibitor)

Select High Blood Pressure Medications

Specialty Medications

he step therapy

rogram encourages

afe and cost-eff ective

medication use.

bcbsil.com

What should I do if I take a drug that

is part of the step therapy program?

If you are already taking a medication that is partof the step therapy program: you may not be affected. Call the Pharmacy Program number on the backof your ID card to fi nd out.

If you start taking a medication that is included inthe step therapy program after the program becomes part of your prescription drug benefi t: your doctorwill need to write you a prescription for a fi rst-line medication or submit a prior authorization request for the prescription before you can receivecoverage for the drug. Your doctor can fi nd prior authorization forms on the provider portal atbcbsil.com. Doctors may also call (800) 285-9426 with questions, or to get a form.

What medications are included in

the step therapy program?

The box above shows examples of drug categories that may be included in the step therapy program. To see a sample list of drugs in these categories, go to bcbsil.com. If you have questions about the step therapy program, or to fi nd out if a particular drug is included in the program, call the Pharmacy Program number on the back of your ID card.

* Additional categories may be added and the program maychange from time to time.

Tools such as step therapy encourage safe and cost-effective medication use, and help manage the rising cost of prescription drugs – for everyone.

Triessent Specialty Pharmacy Program

Through this program, you can have self-administered specialty drugs delivered directly to you or your doctor’s office. Specialty

medications include those used in the treatment of complex medical conditions. Examples include hepatitis C, hemophilia,

multiple sclerosis and rheumatoid arthritis.

View the specialty drug list on Blue Cross Blue Shield website.

When you obtain specialty medications through this program, you also receive the following services at no additional charge:

• Coordination of coverage between you, your doctor and Blue Cross and Blue Shield of Illinois

• Educational materials about your particular condition and information about managing potential medication side effects

• Syringes, sharps containers and other supplies with every shipment for self-injectables

• 24/7/365 phone access to a pharmacist for urgent medication issues

To order through Triessent:

• Have your doctor call in your prescription at (888) 216-6710 or fax it in at (866) 203-6010.

• If you have an existing prescription for a specialty medication, call (888) 216-6710 to transfer your prescription.

• A Triessent coordinator will contact you to arrange delivery of your medication with each order.

If you have questions, please contact Triessent at (888) 216-6710 or call the Pharmacy Program number on the back of your ID

card.

2012 Employee Premiums No Wellness Discount

PPO1 - Weekly

Single 38.09$ 21.28$

EE+1 93.51$ 62.79$

Family 124.63$ 81.20$

PPO1 - Monthly

Single 165.06$ 92.21$

EE+1 405.21$ 272.09$

Family 540.06$ 351.87$

PPO2 - Weekly

Single 24.26$ 13.67$

EE+1 64.25$ 41.94$

Family 85.20$ 55.57$

PPO2 - Monthly

Single 105.13$ 59.24$

EE+1 278.42$ 181.74$

Family 369.20$ 240.80$

Wellness Discount

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Flexible Spending Account Enrollment Form

Step 1: Participant Information*=Required Fields

*Employer Name (Do not abbreviate) *Employee ID Number

- -

*Participant Name (First, MI, Last) *Social Security Number

*Participant Mailing Address Email Address (If provided, all notifications will be sent via email)

*City *State *Zip

- -

Day Telephone *Birth Date (mm/dd/yyyy) *Hire Date (mm/dd/yyyy)

*Pay Frequency (Please circle one):Monthly / Semi-Monthly / Bi-Weekly (24) / Bi-Weekly (26) / Weekly / Other

Gender (Please circle one): Male/Female

Marital Status (Please circle one): Married/Single

Step 2: Employee PremiumsIf you have a payroll deduction for insurance premiums, eligible premiums will be deducted before taxes are calculated. You will automatically be enrolled in thisportion of your Section 125 Plan. However, if you wish, you may opt out of the Employee Premium Conversion part of the Plan by contacting your HR Departmentand filling out the waiver form. *Please Note: Insurance premiums are not eligible for reimbursement with your Medical or Limited Medical Spending Account.

Step 3: Enrollment and Election Information

Medical Spending Account Dependent Care Account Limited FSALimit set by employer Limit set by employer up (If applicable)

to IRS maximum

*Annual Election $

*Number of Pay Periods (Note: If enrolling mid-year, please enterthe number of remaining pay periods within the plan year)

÷

*Per Pay Period Amount (To be deducted each pay period) =

*Date of First Payroll (mm/dd/yyyy)

*Participant Effective Date (mm/dd/yyyy)

Step 4: Optional ServicesPlease select only one. Check with your employer as to which services your plan offers.

Debit CardA debit card pays directly from your Flexible Spending Account at the point-of-sale. Itemized receipts are required for alltransactions that are not auto-substantiated at the point-of-sale.

Auto-EOBAuto-EOB is the automatic crossover of eligible health claims from a participant’s health insurance carrier. Payment is madeautomatically to you from your Flexible Spending Account.

Step 5: Authorization or Refusal*Please select only one.

Participant AuthorizationI authorize my employer to reduce my pay on a per pay period basis as indicated above. I understand my reduction is for one flex plan year and that Icannot change or revoke my election unless I experience a qualifying event in accordance with Internal Revenue Code Section 125 and submit myrequest within a reasonable amount of time as deemed by the IRS and my employer. I am aware of the plan's forfeiture provision and that my SocialSecurity and federal unemployment benefits may be reduced because of my reduced salary for tax purposes. Further, I authorize the release of anyinformation necessary to substantiate claims submitted against my Flexible Spending Account.

Participant RefusalI do not want to participate. I understand that by refusing to participate, I will be unable to enroll this plan year unless I experience a qualifying event inaccordance with Internal Revenue Code Section 125 and submit the change within a reasonable amount of time as deemed by the IRS and my employer.

*Enrollment Type (Please circle one): Open Enrollment Period / New Hire

*Employer Signature (Not required during open enrollment) *Date

*Participant Signature *Date