INVOICE FREQUENCY: MAINTENANCE DEPOSIT - # MONTHS:

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1 CLAIMS FUNDING OPTIONS FOR YOUR FLEXIBLE SPENDING PLANS It is important that the claims funding process work smoothly from both the employer and the vendor s perspective. We have the ability to provide you numerous funding methodologies to give you flexibility and the freedom to continue to use a process similar to one you may already be using. You may even find one that will be easier to implement with your payroll and accounting areas. Please review the options below and choose the option that works best for your group. You will receive a Service Agreement in the mail in the next few weeks that will incorporate the option you choose below. SALARY REDUCTION: Allows you to send in a check or ACH to our offices at the close of each payroll representing the salary reductions just taken from participants for health or dependent care elections. CLAIMS PAID INVOICE: Allows you to receive an invoice for claims paid during the invoicing cycle. MAINTENANCE DEPOSIT: Allows you to have the freedom to ask Benefit Strategies to manage funds associated with claims payments. We request this maintenance deposit so that we may begin immediately funding accounts and debit card transactions while awaiting your salary reductions or invoice payments. The Maintenance Deposit is a calculation based on the equivalent of either 1 or 2 months worth of your participants annual elections. ALL FUNDS RELATED TO CLAIMS SHOULD BE MAILED TO OUR LOCKBOX: PO BOX BOSTON, MA PLEASE CHECK ONE: FUNDING OPTION: MAINTENANCE DEPOSIT - # MONTHS: INVOICE FREQUENCY: PAYMENT DUE WITHIN: Option A Salary Reduction 2 Not applicable At end of payroll cycle Option B Claims Paid Invoice 2 Monthly 5 days from invoice date Option C Claims Paid Invoice 1 Semi-Monthly 5 days from invoice date Authorized Signature Date: Title / Company Name PLEASE SEND THIS COMPLETED FORM TO:

2 MERCHANT CODES SUBSTANTIATION PARAMETERS The attached merchant code substantiation guidelines allow Benefit Strategies to monitor activity in participant accounts using our systems. We typically request receipts according to the levels indicated on these guidelines. Many of our clients see the FlexExpress debit card as a means to provide convenience to their participants, as well as afford them easy access to their plan funds. Our responsibility is to assist you and your participants with finding a balance between debit card usage and the claims substantiation required by the IRS. We ask that you a) review the guidelines and accept them as presented or b) ask us how you can elect to change them as the plan sponsor. Authorized Signature Date: Title / Company Name We accept the parameters as presented. PLEASE SEND TO:

3 Merchant Code Description Max Trans. Amount Auto Review Parameter Specifications 2833 Medicinal Chemicals and Botanicals Yes 2834 Pharmaceutical Preparations 250 Parameter Amount less than In-Vitro and N-Vitro Diagnostics Yes 3827 Optical Instruments and Lenses Yes 3842 Orthopedic and Prosthetic Appliances Yes 3851 Eyeglasses and Eye Safety Shields Yes 4119 Ambulance Services Yes 5047 Dental/Lab/Medical/Opthalmic Hospital Equip & Supp Yes 5048 Opthalmic Supplies Yes 5122 Drugs, Drug Proprietors and Druggist Sundries 250 Parameter Amount less than Wholesale Clubs 250 Parameter Amount less than Discount Stores 250 Parameter Amount less than Department Stores 250 Parameter Amount less than Grocery Stores, Supermarkets 250 Parameter Amount less than Drug Stores and Pharmacies 250 Parameter Amount less than Direct Marketing - Catalog Merchant 250 Parameter Amount less than Direct Marketing - Catalog & Retail Merchant 250 Parameter Amount less than Direct Marketing, NEC 250 Parameter Amount less than Hearing Aids Yes 5976 Orthopedic Goods, Prosthetic Devices Yes 8000 Services-Health Services Yes 8011 Doctors NEC Yes 8021 Dentists, Orthodontists Yes 8031 Osteopathic Physicians Yes 8041 Chiropractors Yes 8042 Optometrists, Opthalmologists Yes

4 8043 Opticians, Optical Goods & Eyeglasses Yes 8044 Optical Goods and Eyeglasses Yes 8049 Chiropodists, Podiatrists Yes 8050 Nursing and Personal Care Facilities Yes 8052 Immediate Care Facilities Yes 8059 Nursing & Personal Care Facilities Yes 8060 Services-Hospitals Yes 8062 Hospitals Yes 8063 Psychiatric Hospitals Yes 8069 Specialty Hospitals, except Psychiatric Yes 8071 Medical and Dental Laboratories Yes 8072 Dental Laboratories Yes 8082 Home Health Care Services Yes 8090 Services-Misc Health & Allied Services,NEC Yes 8093 Specialty Outpatient Facilities, NEC Yes 8099 Medical Services & Health Practitioners, NEC Yes Prepared by Benefit Strategies, LLC / August 2006 Max Transaction Amount: our system will only allow transactions up to this amount to go through at these vendor codes. Auto Review: our system automatically approves amounts as specified in next column. All other transactions will be sent a request for documentation. Parameter Specifications: We choose what the system will automatically approve. We do not request substantiation for amounts less than these amounts. If AutoReview is set to yes, we accept all transactions from those vendors. Participants can only purchase eligible items through those vendors.

5 CO-PAY SUBMISSION FORM The IRS recently announced that certain types of debit card expenses could be automatically substantiated by the third party administrator handling your health care flexible spending accounts (Benefit Strategies). These types of expenses are associated with co-pays at health care providers. Benefit Strategies can auto-substantiate all co-pays associated with your health plans, to include multiples of 5 times each co-pay. Many of our clients see the FlexExpress debit card as a means to provide convenience to their participants, as well as afford them easy access to their plan funds. Our responsibility is to assist you and your participants with finding a balance between debit card usage and the claims substantiation required by the IRS. We ask that you provide us as many co-pay amounts as possible so we may automatically accept all transactions from the merchants associated with those co-pays (i.e. doctors, optometrists, etc.) Please complete the form below and return it to us for processing. We look forward to continuing to provide you and your participants with the best service we can. Co-Pay Description: Sample: Plan Type: Medical Sample: Primary Care Physician Office Visit Co-Pay Amount: PLAN TYPE: Primary Care Physician Office Visit Specialist Office Visit Emergency Room Prescription Drug (Pharmacy) Prescription Drug (Mail Order) Other: Other:

6 PLAN TYPE: Primary Care Physician Office Visit Specialist Office Visit Emergency Room Prescription Drug (Pharmacy) Prescription Drug (Mail Order) Other: Other: PLAN TYPE: Other: Other: Other: Other: Other: Authorized Signature Date: Title / Company Name PLEASE SEND TO:

7 FSA EMPLOYER PORTAL YOUR ON-LINE ACCESS Our Employer Portal will give you on line access to our site with the ability to: DOWNLOAD SCHEDULED REPORTS (Our standard report frequency is monthly. If you require a different cycle (i.e. weekly), please contact our office and we will customize the report frequencies for you.) VIEW FORMS AND PUBLICATIONS VIEW PLAN INFORMATION SUBMIT REQUESTS RIGHT ON LINE You and your HR staff can have access very quickly and easily by completing the form below and returning it to our offices. Your Account Manager may contact you if they need more information to set up your access, otherwise, you will receive an outlining the instructions for on line access, providing you a username and separate communication with a password to log in. Company Name: Address: City: State: Zip: Main Phone: Main Fax: Confidential Fax: Please provide internet access to: CONTACT 1: CONTACT TYPE: (i.e. HR, Payroll, Accounting) NAME: PHONE: CONTACT TITLE: CONTACT 2: CONTACT TYPE: (i.e. HR, Payroll, Accounting) NAME: PHONE: CONTACT TITLE: CONTACT 3:* CONTACT TYPE: (i.e. HR, Payroll, Accounting) NAME: PHONE: CONTACT TITLE: *(More than three users is available just let us know!) PLEASE SEND THIS COMPLETED FORM TO: