EMPLOYEE BENEFIT OPTIONS Non Managers PLAN YEAR: 7/1/2013 6/30/2014 Medical PLAN YEAR: 7/1/ /31/2013 MBA Master Plans

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1 EMPLOYEE BENEFIT OPTIONS Non Managers PLAN YEAR: 7/1/2013 6/30/2014 Medical PLAN YEAR: 7/1/ /31/2013 MBA Master Plans W e r e c o g n i z e t h a t b e n e f i t s a r e a n i m p o r t a n t p a r t o f y o u r t o t a l c o m p e n s a t i o n p a c k a g e. O u r b e n e f i t p r o g r a m p r o v i d e s c o m p e t i t i v e a n d v a l u a b l e b e n e f i t s f o r y o u a n d y o u r d e p e n d e n t s w h i l e m a n a g i n g t h e i n c r e a s i n g c o s t s. B e c a u s e y o u a r e a v a l u e d e m p l o y e e w e o f f e r y o u c o m p r e h e n s i v e c o v e r a g e w i t h t h e f r e e d o m o f c h o i c e a n d t a x s a v i n g s f e a t u r e s. A s i t i s t i m e f o r y o u t o s e l e c t y o u r b e n e f i t o p t i o n s a n d e n r o l l f o r t h e p l a n y e a r, t h i s b r o c h u r e p r o v i d e s a s u m m a r y o f t h e p r o g r a m s. I f y o u h a v e a n y q u e s t i o n s r e g a r d i n g y o u r c h o i c e s, p l e a s e c a l l y o u r d e d i c a t e d e n r o l l m e n t s p e c i a l i s t a t N E ; s e e h o w t o e n r o l l. Medical BENEFIT Dental (MBA Master) Vision (MBA Master) Voluntary LTD (MBA Master) Worksite Benefits (MBA Master) YOUR BENEFITS AT A GLANCE ELIGIBLE EMPLOYEE Full Time employees working 30 hours 1 st of the following after 90 days of service ELIGIBLE DEPENDENTS *Spouse & Domestic Partners (same/opposite sex) *Children to age 26 (some states may have extension) *Spouse & Domestic partners (same/opposite sex) *Children to age 19 / 26 if full time student *Spouse & Domestic partners (same/opposite sex) - - How to Enroll for Benefits: Benefits eligible employees must call NES any Tuesday at least 30 days prior to the benefits eligibility date. 1) Review benefits enrollment materials 2) Have Date of Birth and SSNs for you and your dependents to be enrolled 3) Call Introduce yourself as a BDE Taco Bell employee 4) An NES enrollment specialist will assist you with any questions, review all your benefit options and finalize your enrollment. 5) Complete the universal paper application & return to enroller 6) HSA deductions form to be returned to MBA with banking information to enable deductions and funding [Optional when enrolling in the HSA qualified 130/131 medical plan] 7) Allstate enrollers will accept elections

2 THE TAX ADVANTAGE One of the advantages of our program is that any payroll deduction you authorize as payment for medical and dental benefits is made on a pre-tax basis. This is done with our Section 125 Plan. When you elect to pay for these benefits pre-tax, you save because you are paying less in taxes. You do not pay Federal Income or Social Security taxes, therefore, you lower your taxable income. This will allow you to take home more in your paycheck, decreasing the net cost of the benefit you are purchasing. Current IRS regulations state that benefit choices cannot be changed in the middle of a plan year unless you experience a qualifying event. ELIGIBILITY & ENROLLMENT You are eligible to enroll if you meet the requirements listed on page one. Making Changes: You may not change your benefit selections or any contributions made to the plan during the plan year unless there is a change in family or employment status which includes the following qualifying events: Marriage, divorce or legal separation Birth, adoption or change in custody of a child Death of dependent Change in employment status of either you or your spouse which affect benefits Any changes must be reported within 30 days of the actual event. If notification to Human Resources is not made within the required time period, you will not have the option to update your benefit coverage until the next annual enrollment period. Please take your time and make sure to understand your decision. MBA Pre-Month Pre-month is a deduction equal to one month of your employee benefit contribution amount. We require a pre-month on file so that funds are available to pay the insurance carrier invoices, which are due on the first of the month for that month s coverage. Your pre-month contribution amount will be split over a number of pay periods to reduce financial strain, and will be deducted in addition to your normal contribution amounts. Please note: Allstate American Heritage supplemental policies are not subject to the pre-month. Please call MBA with any questions regarding the premonth or changes to this payroll function.

3 EMPLOYEE ENROLLMENT CHECKLIST: Discuss benefits with the enrollment specialist Complete universal enrollment form for the following coverages: Medical (BCBS) Dental (Humana) Vision (Humana) Voluntary LTD Select any voluntary Allstate supplemental coverages with enroller (Cancer, Accident, Critical Illness or Universal Life) HSA BANKING If enrolling in an HSA qualified health plan, you have the option of opening an HSA bank account for pre-tax deductions to fund the account to use for qualified expenses. 1. Open an HSA bank account through your personal bank of choice 2. Complete the HSA deduction payroll form to set up deductions (banking information needed: name/address/phone/checking & routing account numbers) 3. Fax or HSA deduction form directly to MBA: fax or at or as soon as you establish the bank & wish to begin funding via payroll deduction HSA Information Good HSA resource: Pre-tax possibility with banking arrangement Can go to any bank to establish HSA Bank Account or use carrier partner Ineligible parties to participate in pre-tax deductions for HSA funding: o 2% shareholders of partnerships, S Corp, LLC or self-employed (above the line deductions available at tax o o o o time, consult with your CPA) Enrolled in Medicare, Medicaid or Tricare Not enrolled on a HSA qualified health plan If you have other first dollar medical coverage If claimed as a dependent on someone else s tax return

4 MEDICAL INSURANCE Blue Care: HMO Plan options Blue Care is a network of physicians, hospitals, and other health care providers that serve the employees and their families who join this plan. You DO need to select a primary care physician. If you see any other general doctor other than your selected PCP, the specialist copay applies Open Access -no referral to specialist- You will be able to go directly to any in network physician that is listed. When you want health care, you must stay in the network. There is no coverage outside of the network other than true emergency care. Residents living outside of Florida may not enroll on the Blue Care plans Blue Options: PPO Plan options Blue Options are a network of physicians, hospitals, and other health care providers that serve the employees and their families who join this plan. Each time care is needed, you have the freedom to decide whether or not to use their network of PPO providers. If you visit the network providers, the plan pays the highest benefits. Services from providers outside the network are covered, but you pay more towards the cost of your treatment. PPO plans include out of network benefit options. Residents living outside of Florida can enroll on Blue Options plans and utilize the Blue Card network through Network Information: Blue Care and Blue Options are two different networks. Please research to ensure which plans your physicians participate in. How to find a provider: Find a Doctor Step 1: Enter Search options Step 2: Select the Plan (network name) o Blue Care o Blue Options (Non Florida residents go to for search) Step 3: Location

5 MEDICAL INSURANCE OVERVIEW PLAN NAME: IN NETWORK BENEFITS Calendar Yr Deductible: Blue Care HMO HSA Qualified (130/31) Blue Care HMO 47 Blue Options 5770 Individual/Family $1,500 / $3,000 Non Embedded $1,500 / $4,500 $1,000 / $3,000 Calendar Yr Maximum Out of Pocket: Individual/Family $4,500 / $9,000 Non Embedded $4,500 / $9,000 $3,500 / $7,000 What does out of pocket include? Deductible, Coinsurance & Copays Deductible, Coinsurance & Copays excluding Rx Hospital Per Confinement 20% after Ded 20% after Ded 20% after Ded Outpatient Hospital Services 20% after Ded 20% after Ded 20% after Ded Emergency Room [for emergency only] 20% after Ded $250 Copay $200 Copay Physician Fees for Inpatient, Outpatient & ER 20% after Ded 20% after Ded $100 Copay Urgent Care (for urgent care only) 20% after Ded $60 Copay $50 Copay Office Visits: Primary / Specialist 20% after Ded $30 / $55 Copay $25 / $45 Copay Preventive Care (Routine Exams): $0 $0 $0 X-Ray & Lab (Freestanding Lab) Complex Imaging: MRI's, CAT and PET Scans OUT OF NETWORK BENEFITS 20% after Ded 20% after Ded Lab: $0 Xray: $50 Copay $250 Copay (Hospital: 20% after Ded) Lab: $0 Xray: $50 Copay $200 Copay (Hospital: 20% after Ded) Cal Yr Deductible: Individual/Family No Coverage No Coverage $3,000 / $6,000 Cal Yr Maximum Out of Pocket: No Coverage No Coverage Individual/Family $7,000 / $14,000 Coinsurance No Coverage No Coverage 50% PRESCRIPTION DRUGS: Retail: Level 1/ 2 / 3 / 4 Mail Order Prescriptions $10/ $50/ $80 after Ded Generic Mandatory (30 Day Supply) $25/ $125/ $200 after Ded(90 Day Supply) $10 / $50 / $80 Generic Mandatory (30 Day Supply) $25 / $125 / $200 (90 Day Supply) $10 / $30 / $50 Generic Mandatory (30 Day Supply) $25 / $75 / $125 (90 Day Supply) Out of Network No Coverage No Coverage 50% PER PAY DEDUCTIONS (24 per year) Employee $36.54 $58.42 $91.43 Employee & Spouse $96.90 $ $ Employee & Child(ren) $40.88 $95.49 $ Employee, Spouse & Child(ren) $ $ $ *Non Embedded - No one in the family is eligible for benefit until the family limit has been met. The individual limit does not apply if enrolled with dependents. *Pre-Existing Limitations This plan may have limitations included on the policy for adults age 19 and up. If you have had 12 months of continuous coverage with no more than a 63 day gap, please provide the certificate of creditable coverage from the prior carrier to the new carrier to credit any limitations. *This is an Insurance Summary. It is not a contract or a policy. The summary highlights the benefits available under the plans; a more complete explanation of benefits and limitations is contained in the contract.

6 DENTAL INSURANCE THROUGH MBA Plan renews 1/1 each year How to find a Dentist: Find a dentist PPO Enter Zip Code --Go Network: PPO/Traditional Preferred Go Select search criteria--go PLAN NAME: HUMANA LOW Texas employees eligible for the Middle Plan only HUMANA MIDDLE HUMANA HIGH IN NETWORK BENEFITS Calendar Year Deductible: Individual / Family $50 / $150 $50 / $150 $50 / $150 Waived for Preventive Yes Yes Yes Calendar Year Maximum $1,000 $1,500 $2,000 Basis of Payment Negotiated Fee Negotiated Fee Negotiated Fee Preventive / Basic / Major 100% - 80% - 50% 100% - 80% - 50% 100% - 90% - 60% Periodontics & Endodontics Major: 50% Basic: 80% Basic: 80% Benefit Waiting Periods Orthodontia OUT OF NETWORK BENEFITS Calendar Year Deductible: Individual / Family Late Entrants & Orthodontia: 12 Months (A Late Entrant is anyone who enrolls on the plan after their initial eligibility date; late entrants will have preventive coverage only in the first 12 months) 50% to Lifetime Max $1,000 (Child Only) 50% to Lifetime Max $1,500 (Child Only) 50% to Lifetime Max $1,500 (Adult & Child) Combined with in network $50 / $150 $100 / $300 Waived for Preventive Yes Yes Calendar Year Maximum Combined with in network Basis of Payment In network fee In network fee schedule schedule Usual & Customary Preventive / Basic / Major 80% - 80% - 50% 100% - 80% - 50% 100% - 80% - 50% PER PAY DEDUCTIONS (24) Employee $8.86 $13.81 $20.53 Employee & Spouse $17.04 $27.09 $41.35 Employee & Child(ren) $24.51 $39.18 $47.44 Employee, Spouse & Child(ren) $32.69 $52.47 $68.26 This is an Insurance Summary. It is not a contract or a policy. The summary highlights the benefits available under the plans; a more complete explanation of benefits and limitations is contained in the contract.

7 VISION INSURANCE THROUGH MBA Plan Year renews 1/1 each year How to find a Provider: Humana Vision VCP provider locator Enter Zip Code --Enter. PLAN NAME: Exam Lenses: Single Vision / Bifocal / Trifocal Frames HUMANA VISION PLAN $10 Copay $15 Copay $50 Wholesale allowance; $100-$150 approximate retail value Contact Lenses - Elective $150 Allowance Contact Lenses - Medically Necessary 100% Contacts in Lieu of Spectacles? Yes Laser Vision Correction Frequency of Benefits: Exams Lenses Frames Various Lasik per eye copays apply when TLC Vision Lasik Centers used (ranging $895 - $2,300) From Date of Service Once Every 12 Months Once Every 12 Months Once Every 24 Months See Carrier plan documents for out of network details PER PAY DEDUCTIONS (24) Employee $3.67 Employee & Spouse $7.33 Employee & Child(ren) $6.96 Employee, Spouse & Child(ren) $10.95 EMPLOYEE PAID VOLUNTARY LTD Optional coverage available for voluntary long term disability, see carrier flyer for details

8 TO: ALL EMPLOYEES RE: EARNED INCOME TAX CREDIT AND EXCITING NEW BENEFITS FOR ALL EMPLOYEES We are excited to offer our employees information on the Earned Income Tax Credit program. The Earned Income Tax Credit (EITC) is a refundable credit for people who earn low-to-moderate incomes. The EITC reduces the tax you owe and if you qualify it may give you a refund even if you don t owe any taxes. In addition, the Federal Government will REFUND any earned income credit not claimed by you for the past 3 years! You may have as much as $3,000 total owed to you regardless of where you were working during that time. Also, in our continuing search to provide you greater employee benefits, ALL employees will also have the opportunity to learn about and enroll in various voluntary benefits, offered by Allstate, including valuable and portable insurance coverages for you and your family members like: Cancer Accident Critical Illness Universal Life In addition, all employees will be receiving a FREE Prescription Drug Discount Card

9 Premium Assistance Under Medicaid and the Children s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your employer, your State may have a premium assistance program that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for these programs, but also have access to health insurance through their employer. If you or your children are not eligible for Medicaid or CHIP, you will not be eligible for these premium assistance programs. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial KIDS NOW or to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must permit you to enroll in your employer plan if you are not already enrolled. This is called a special enrollment opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, you can contact the Department of Labor electronically at or by calling toll-free EBSA (3272). If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. The following list of States is current as of July 31, You should contact your State for further information on eligibility ALABAMA Medicaid Website: Phone: ALASKA Medicaid Website: Phone (Outside of Anchorage): Phone (Anchorage): ARIZONA CHIP Website: Phone (Outside of Maricopa County): Phone (Maricopa County): IDAHO Medicaid and CHIP Medicaid Website: Medicaid Phone: CHIP Website: CHIP Phone: INDIANA Medicaid COLORADO Medicaid Medicaid Website: Medicaid Phone (In state): Medicaid Phone (Out of state): FLORIDA Medicaid Website: Phone: GEORGIA Medicaid Website: Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: MONTANA Medicaid Website: clientindex.shtml Phone: NEBRASKA Medicaid

10 Website: Phone: IOWA Medicaid Website: Phone: KANSAS Medicaid Website: Phone: KENTUCKY Medicaid Website: Phone: LOUISIANA Medicaid Website: Phone: MAINE Medicaid Website: Phone: TTY MASSACHUSETTS Medicaid and CHIP Website: Phone: MINNESOTA Medicaid Website: Click on Health Care, then Medical Assistance Phone: MISSOURI Medicaid Website: Phone: Website: Phone: NEVADA Medicaid Medicaid Website: Medicaid Phone: NEW HAMPSHIRE Medicaid Website: Phone: NEW JERSEY Medicaid and CHIP Medicaid Website: dmahs/clients/medicaid/ Medicaid Phone: CHIP Website: CHIP Phone: NEW YORK Medicaid Website: Phone: NORTH CAROLINA Medicaid Website: Phone: NORTH DAKOTA Medicaid Website: Phone:

11 OKLAHOMA Medicaid and CHIP Website: Phone: OREGON Medicaid and CHIP Website: Phone: PENNSYLVANIA Medicaid Website: Phone: RHODE ISLAND Medicaid Website: Phone: SOUTH CAROLINA Medicaid Website: Phone: SOUTH DAKOTA - Medicaid Website: Phone: TEXAS Medicaid Website: Phone: UTAH Medicaid and CHIP Website: Phone: VERMONT Medicaid Website: Phone: VIRGINIA Medicaid and CHIP Medicaid Website: HIPP.htm Medicaid Phone: CHIP Website: CHIP Phone: WASHINGTON Medicaid Website: Phone: ext WEST VIRGINIA Medicaid Website: Phone: , HMS Third Party Liability WISCONSIN Medicaid Website: Phone: WYOMING Medicaid Website: Phone: To see if any more States have added a premium assistance program since July 31, 2012, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services EBSA (3272) , Ext OMB Control Number (expires 09/30/2013)