Lowe Automotive Group Health Insurance Open Enrollment & FSA Enrollment Will be Nov 19th – Dec 2nd (Coverage will begin Jan 1, 2015) See your Manager if you are not currently on the health insurance plan, or need to add or remove someone from your existing plan. All forms to be turned in by Dec 2, 2015

We are changing health insurance coverage to United Healthcare We need all forms turned in by Dec 2nd so we can get cards to everyone by Jan 1, 2015

Important Information on the FSA Plan If you currently have an FSA Debit Card, keep it. The card will be reused in 2015

Lowe Automotive Group There are 2 plans to choose from: Standard or Premium plan. Our employees will have the ability to choose the plan they would like to use. We are able to help offset some of the employee contribution increase by working with the insurance company to have a healthier work force; you may qualify for monthly discounts.

Health/Dental Rates Effective January 1, 2015 Coverage Type 

Premium Plan

Standard Plan

Employee 

$185.00 Monthly

$92.50 /twice a month

$155.00 Monthly

$77.50 /twice a month

Employee + Spouse 

$695.00 Monthly

$347.50 /twice a month

$640.00 Monthly

$320.00 /twice a month

Employee + Child(ren) 

$585.00 Monthly

$292.50 /twice a month

$540.00 Monthly

$270.00 /twice a month

$1110.00 Monthly

$555.00 /twice a month

$1040.00 Monthly

$520.00 /twice a month

Family 

Discounts Available for Wellness Program/Dental Check-up/Tobacco Free/BMI See Your Manager for more information on Discounts!

You can earn up to $70 discount each month by Participating in the Wellness Blood Screening You have until November 26th to complete the Blood/Dental screenings. If you participate and qualify for all of the discounts, your rate does not go up in 2015

Lowe Automotive Group      Tobacco Free Affidavit    In order to enroll you in the proper level of benefit plan contribution, it is necessary to confirm your  Tobacco Free status.   At Lowe Automotive Group, we offer a premium contribution discount to  Tobacco Free plan members. The discount is only offered if you abstain from Tobacco  (smoked/chewed).  Therefore, please indicate your Tobacco status below by checking the  appropriate box.        I am and pledge to remain Tobacco Free during the upcoming benefit plan year.  Please apply  the Tobacco Free discount to my premium contributions.    I am not nor do I pledge to remain Tobacco Free during the upcoming benefit plan year.  I  understand I am not eligible for the Tobacco Free discount.      Please sign this Affidavit form below with your full name:    In signing this form, I understand that if I am found to be providing untruthful information on this  Affidavit, or fail to report a change in Tobacco habits, it may result in disciplinary action including  the revocation of the premium discount.  I also understand that it is my responsibility to  immediately inform my Manager if I begin or resume Tobacco at any time.      Company Location:  Employee Name (Print):    Employee Signature:  Date:     

Oral Health Screening Form Dear Healthcare Professional: Lowe Automotive Group is committed to improving health and wellbeing among its employees. As part of that commitment, employees can earn wellness discounts by participating in an oral health screening. Please assist your patient in earning their wellness points by completing the form below. Thank You!

Patient Name

Patient DOB

Printed Name of Physician

Date

Physician Signature

Visit must occur before (Dec 1, 2014), and form be received by Manager in order to receive wellness points

Health Insurance Plans Effective Date:  January 1, 2015

Lowe Automotive Warehouse

United Healthcare Plans 2015 Standard Plan 100/70, $5,000 United Healthcare $5,000 $5,000 per member ‐ max $10,000 100%

Premium Plan 80/50, $3,000 United Healthcare $3,000 $3,000 per member ‐ max $9,000 80%

Out‐of‐Pocket Maximum

Individual  Family  Deductible, Co‐pays and Rx apply towards Out‐of‐Pock

$6,350 $12,700 Yes

$5,000 $10,000 Yes

Office Visit Copayment ‐ Primary/Specialist

$30/$50

$20/$40

Deductible then Coinsurance

Deductible then Coinsurance

Deductible then Coinsurance Deductible then Coinsurance Deductible then Coinsurance Deductible then Coinsurance Deductible then Coinsurance Not included $100 Deductible the $10/$35/$70 Same as Tier 3 $100 Deductible then 2.5x copay Deductible then Coinsurance

$150+20%/$50 Deductible then Coinsurance Deductible then Coinsurance Deductible then Coinsurance Deductible then Coinsurance Not covered $10/$35/$60 Same as Tier 3 2.5x copay Deductible then Coinsurance

Yes To Age 26

Yes To Age 26

$5,000

$6,000

$5,000 per member ‐ max $15,000 70%

$6,000 per member ‐ max $18,000 50%

$10,000 + UCR $20,000 + UCR

$10,000 + UCR $20,000 + UCR 

Deductible then Coinsurance

$150+20%

Benefit IN‐NETWORK BENEFITS  Calendar Year Deductible                      

Individual  Family 

Coinsurance

Essential Health Benefits 1. Ambulatory Patient Services 2. ER/Urgent Care Copayment‐ Waived if Admitted 3. Hospitalization 4. Lab/Diagnostic Testing  5. Maternity & Newborn Care 6. Mental Health & Substance Abuse 7. Pediatric Services (Oral & Vision Care) 8. Rx ‐ Tier 1/Tier 2/Tier 3/Tier 4/Tier 5 ‐ 30 Day Supply Tier 4/Tier 5              Mail Order ‐90 Day Supply 10. Rehabilitative & Habilitative Services Medicare Part D Creditable Coverage Dependent Child Age Limit  OUT‐OF‐NETWORK BENEFITS Calendar Year Deductible                      

Individual  Family 

Coinsurance Out‐of‐Pocket Maximum‐ UCR (Deductible Included)               

Emergency Room Copayment Rates Employee Employee + Spouse Employee + Child(ren) Family

Individual  Family 

Standard Plan $155.00 $640.00 $540.00 $1,040.00

The Cornerstone Insurance Group

Premium Plan $185.00 $695.00 $585.00 $1,110.00

Lowe Automotive Group Health Insurance Worksheet Pricing Effective Jan 1, 2015 Total Premium Costs Premium Plan + Dental =$549.00

Standard Plan + Dental = $520.00

Employee Contribution before credit Premium

Standard

Employee

185.00

155.00

Employee+Spouse

695.00

640.00

Employee+Child(ren)

585.00

540.00

Family

1110.00

1040.00

 You Must Participate in Wellness Blood Screening to Qualify for ANY discounts $15 Wellness

$30 Tobacco Free

$15 Dental Exam

$10 BMI

Employee              Spouse                  Child/Children   Total Discount =

EmployeeTotal Contribution Less Total Discount = Monthly Amt Monthly Amt/2= Biweekly deduction Location

Employee Name **You must turn in either a copy of your Explaination of Benefits from Guardian Ins showing a   Dental Visit in 2014 or have your Dentist complete the attached Oral Health Screening form to  Qualify for the Dental Discount

Lowe Automotive Dual Option Selection I, __________________________________, choose the following option for my health insurance coverage with United Healthcare effective January 1, 2015: Warehouse/Store Location: ___ Base Option Plan (Standard Plan) (100%, $5000 Ded, $30/$50 Copays, $10/$35/$70 Rx after Deductible, No Copays ER/UC) $145.00/month(Discounts Available) for Employee, see other page for Dependent Rates ___ Buy-Up Option Plan (Premium Plan) (80%, $3000 Ded, $20/$40 Copays, $10/$35/$60 Rx, $150+20%/$50 ER/UC Copays) $175.00/month(Discounts Available) for Employee, see other page for Dependent Rates

Please check the correct coverage type: (If the coverage type chosen below is different from your current enrollment, you will need to complete an enrollment/change form, check box also)

New Participant – Enrolling for first time (Will need additional enrollment forms from Manager)

I am adding / deleting dependents (Will need additional forms from Manager)

___ Employee Only ___ Employee/Spouse ___ Employee/Child(ren) ___ Family ___ Waive Coverage

Employee Signature: _________________________

Benefit and insurance issues important to you—brought to you by the insurance specialists at The Cornerstone Insurance Group.

Lowe Automotive Flexible Spending Accounts Information for Employees Plan Year January 1, 2015- December 31, 2015 ________________________________________________________________________________________________________________________________________

Flexible spending accounts, or FSAs, provide you with an important tax advantage that can help you pay health care and dependent care expenses on a pretax basis. By anticipating your family’s health care and dependent care costs for the next plan year, you can actually lower your taxable income. Essentially, the Internal Revenue Service (IRS) set up FSAs as a means to provide a tax break to employees and their employers. As an employee, you agree to set aside a portion of your pre-tax salary in an account, and that money is deducted from your paycheck over the course of the year. The amount you contribute to the FSA is not subject to Social Security (FICA), federal, state or local income taxes – effectively adjusting your annual taxable salary. The taxes you pay each paycheck and collectively each plan year can be reduced significantly, depending on your tax bracket. And, as a result of the personal tax savings you realize, your spendable income will increase.

Gross income FSA contributions Gross income Estimated taxes: Federal State FICA After-tax earnings Eligible out-of-pocket medical and dependent care expenses Remaining spendable income Spendable income increase

Without FSAs $30,000 $0 $30,000

With FSAs $30,000 -$5,300 $24,700

-$2,550* -$900** -$2,295 $24,255

-$1,755* -$741** -$1,890 $20,314

-$5,300

$0

$18,955

$20,314

--

$1,359

* Assumes standard deductions and four exemptions. ** Varies, assume 3%. The example above is for illustrative purposes only. Every situation varies and it is recommended you consult a tax advisor for all tax advice.

The example that follows illustrates how a flexible spending account can save you money. Bob and Jane’s combined gross income is $30,000. They have two children and file their income taxes jointly. Since Bob and Jane expect to spend $2,000 in adult orthodontia and $3,300 for daycare next plan year, they decide to direct a total of $5,300 into their FSAs. (See table)

The Health Care Reimbursement FSA The Health Care Reimbursement FSA lets you pay for certain IRS-approved medical care expenses not covered by your insurance plan with pre-tax dollars. For example, cash that you now spend on deductibles, copayments or other out-of-pocket

The Cornerstone Insurance Group 721 Emerson Road, Suite 500 St. Louis, MO 63141 Administration Department: 314.373.2930 Fax: 314.373.2931 [email protected]

medical expenses can instead be placed in the Health Care Reimbursement FSA pre-tax. The annual maximum contribution to the Health Care Reimbursement FSA is $2,550. Once enrolled, you will be able to collect reimbusements either by filing a claim with The Cornerstone Insurance Group, or by using your Benny PrePaid Visa. This Visa card gives you the opportunity to pay for eligible medical expenses at the point of service, directly from your account.

In order for dependent care services to be eligible, they must be for the care of a tax-dependent child under age 13 who lives with you, or a tax-dependent parent, spouse or child who lives with you and is incapable of caring for himself or herself. The care must be needed so that you and your spouse (if applicable) can go to work. Care must be given during normal working hours – Saturday night babysitting does not qualify – and cannot be provided by another of your dependents.

Eligible Expenses Eligible health care expenses for the Health Care Reimbursement FSA include more than just your deductible and copayments. Generally, any medically necessary health care expense that you can deduct on your tax return is considered an eligible expense. Some examples include:

Is the FSA Program Right for Me? The Flexible Spending Accounts are beneficial for anyone who has out-of-pocket medical, dental, vision, hearing or dependent care expenses beyond what his/her insurance plan covers.

Hearing services, including hearing aids and batteries Vision services, including contact lenses, contact lens solution, eye examinations, eyeglasses and Lasik surgery Dental services and orthodontia Chiropractic services Acupuncture Prescription contraceptives OTC drugs – with a Dr.’s prescription – IMPORTANT – you WILL be able to use your debit card for OTC drugs IF you get them filled through a pharmacy.

• •

• • • • •

For more information about eligible medical expenses, please refer to IRS Publication 502, Medical and Dental Expenses, available at www.irs.gov/publications/p502/index.html.

The Dependent Care FSA The Dependent Care FSA lets you use pre-tax dollars toward qualified dependent care. The annual maximum amount you may contribute is $5,000 (or $2,500 if married and filing separately) per calendar year. If you elect to contribute to the Dependent Care FSA, you may be reimbursed for: •

The cost of child or adult dependent care

•

The cost for an individual to provide care either in or out of your house

•

Nursery schools and preschools (excluding kindergarten)

It’s easy to determine if an FSA will save you money. At enrollment time, you will need to determine your annual election amount. Estimate the expenses that you know will occur during the year. These include out-of-pocket expenses for yourself and anyone claimed as a dependent on your taxes. If you had $100 or more in recurring or predictable expenses, the accounts can help you stretch your dollars. How Do the Accounts Work? If you decide to enroll in one or both of the accounts, your contributions are taken out of each paycheck – before taxes – in equal installments throughout the plan year. These dollars are then placed into your FSA. When you have an eligible health care or dependent care expense, you must submit a claim form along with an itemized receipt to be reimbursed from your account. Claims must be received by March 31st of 2016 for reimbursement of 2015 plan year expenses. The Health Care Reimbursement FSA will reimburse you for the full amount of your annual election (less any reimbursement already received), at any time during the plan year, regardless of the amount actually in your account. The Dependent Care FSA will only reimburse you for the amount that is in your account at the time you make a claim. Any funds left in the Dependent Care account that cannot be claimed after the end of the plan year will be forfeited. For the healthcare FSA, you may rollover up to $500 of unused funds at the end of the plan year into the following plan year. This amount is added to your annual election amount for the following plan year.

This brochure is for informational purposes only and is not intended to replace the advice of an insurance professional.

Lowe Automotive ~ Plan Year 1/1/2015 – 12/31/2015 FLEXIBLE SPENDING PLAN ENROLLMENT FORM PLEASE PRINT. All information is required or your enrollment cannot be processed. Employee Name - First ______________________________________________ Last __________________________________________ SSN __ __ __-__ __-__ __ __ __

Date of Birth __ __ /__ __/__ __ __ __

Home Address __________________________________________________________________ Apt. ___________________________ City ____________________________________________________________ State __ __ Home Phone (__ __ __) __ __ __-__ __ __ __

Zip __ __ __ __ __ __

Email Address (required) ________________________________________________________

I wish to participate. (Sign and return completed form)

I do not wish to participate. (Sign form and return)

Option 1 – Medical Expense FSA – reimburses medical expenses incurred by you or your family which are not paid by insurance.

Expenses must be for necessary health care expenditures including physician and facility care, RX, over the counter drugs with a Dr.’s note, dental/orthodontia treatment and visions services. Specific expenses that are NOT eligible include cosmetic procedures, insurance premiums and general health promotion services and products. You may elect up to $2,550 for this account.

YES

I elect to contribute $__ , __ __ __ .00 for the PLAN YEAR, which is $__ __ __ . __ per pay period to fund my account that pays qualified out-of-pocket healthcare expenses.

NO

I decline this option for this plan year and understand that I will lose all tax savings that I could receive as a participant.

–

xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Option 2 – Dependent Care Expense FSA reimburses employment necessitated dependent care expenses. Care must be for persons who are your XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX dependents for income tax purposes and who reside with you. Eligibility is limited to dependents under age 13, unless care is required due to disability. You may elect up to $5,000 for this account. PLEASE NOTE – you must acquire the Tax ID of your dependent care provider to benefit from this account. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX YES I elect to contribute $__ , __ __ __ .00 for the PLAN YEAR, which is $__ __ __ . __ per pay period to fund my XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX account that pays qualified dependent care expenses. Please list your dependents below or go to XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX https://CIGPART.lh1ondemand.com XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX NO I decline this option for this plan year and understand that I will lose all tax savings that I could receive as a participant.

Debit Cards Yes! I need a new debit card

Direct Deposit Authorization – Please go to the employee portal to securely enter or update banking information: https://CIGPART.lh1ondemand.com

Please reload my current card Please list eligible dependents below. You may also go to https://CIGPART.lh1ondemand.com to enter dependents. om/

Name: SSN: Relationship: Date of Birth

Name: SSN: Relationship: Date of Birth

Name: SSN: Relationship: Date of Birth

Name: SSN: Relationship: Date of Birth

IMPORTANT- Please read the following before signing this enrollment form. My Employer and I agree that my taxable income will be reduced each pay period during the year by an equal portion of the benefit elections (selected above) set forth above and that qualified expenses will be paid on a tax-free basis. I understand that I may change my election in the event of certain changes in my status and that prior to the first day of each plan year; I will be offered the opportunity to change my benefit election for the upcoming plan year. I acknowledge that I have received, read and understand the Summary Plan Description. I understand that the take care flex benefits card is available to pay only qualified expense and that qualified expenses paid with the card cannot be reimbursed by any other plan and that I will not seek reimbursement for expenses paid with the card from any other source. I understand that when using the flex benefits card I must keep all receipts and that, on occasion, I may be asked for documentation of charge made with my card. I also understand that if a payment is made that is not for qualified expenses, I will repay my employer. For any expenses not repaid by me, I authorize my employer to deduct the amount from my paycheck (if permitted by state law)

Employee Signature__________________________________

Date____________________