Benefit Plans Administrative Services BPAS 3/9/2020

(ii) the Participant will not seek reimbursement for any expense paid with the electronic payment card under any other plan covering benefits. The electronic payment card shall include a statement providing that each use of the card shall constitute a reaffirmation of the certification. (4) The electronic payment card may be used only at merchants who are health care providers (e.g., doctor's office, hospital, pharmacy, etc.) or other merchants identified in applicable IRS guidance. (5) Each time the electronic payment card is used,a Participant shall obtain and retain a third party statement from the health care provider containing the information necessary to substantiate that the expense paid by the card was an Eligible Expense. (6) Claims shall be substantiated if one of the following conditions is satisfied: (i) The Participant provides, upon request by the Claims Administrator(or its designee), the third party statement with respect to the claim. (ii) The payment was made to a merchant who is a health care provider and it matches a specific co-payment the Participant has under a group medical or group dental plan sponsored by the Adopting Employer or a multiple of that co-payment of not more than five (5) times the dollar amount of the co-payment. (iii) The payment was made to a merchant who is a health care provider and is for an expense with the same amount, duration, and health care provider as a previously approved expense under this Plan. (iv) The payment was made to a merchant who is a health care provider and the electronic claim file with respect to the expense is accompanied by an electronic or written confirmation from the health care provider that verifies the nature and amount of the expense and that the expense is an Eligible Expense. (v) The electronic payment card is used at a merchant (of any kind) that participates in an inventory information approval system developed by the card provider that verifies, at the time of purchase, that the goods being purchased constitute medical care. (7) Special rules apply to the use of the electronic payment card to purchase over- the-counter drugs and medicines other than insulin. Notwithstanding the rules described above regarding the use of the card to purchase medical care, the card may be used to purchase such over-the-counter drugs and medicines only in the following circumstances: (i) At any 90% pharmacy if the expense is substantiated after the purchase in accordance with paragraph (6)(i) above. (ii) At drug stores, pharmacies, non-health care merchants that have pharmacies, and mail order or web-based merchants that sell prescription drugs if(a) the cardholder presents the prescription to the ©2017 Hitesman&Wold,P.A. 10 Funded Post-Employment HRA Basic Plan Document(Single Employer Non-ERSA)