1. Company Name/logo

2. Effective Date: (Carrier Name) HSA Referral RequiredNo Deductible 2 X Dependents $2,500/$5,000 Office Visits80% after Deductible Specialist Visits80% after Deductible X-Ray*80% after Deductible Emergency Room80% after Deductible Out Patient Surgery80% after Deductible Hospitalization80% after Deductible Prescription Card()% after Deductible Maximum Out of Pocket$5,000/$10,000 *

3.  HRA- Health Reimbursement Arrangement ◦ Is a pre-tax reimbursement benefit that will reimburse you for certain out of pocket medical expenses. The HRA is funded by your employer! ◦ Your company HRA will reimburse you up to $() if you have single coverage and $() if you have employee+ dependent coverage.

4. ◦ (Company Name) HRA will reimburse the following expenses:  Expenses applied towards you deductible  Office Copays  RX Copays  Coinsurance  As previously stated, the HRA will reimburse up to $() for single coverage and $() for employees with dependent coverage.

5. If you have an HSA compatible plan, you should NOT be responsible to pay any form of payment at the time of service, unless purchasing RX expenses.

8. Visit www.oca125.com/drugs/ for more informationwww.oca125.com/drugs/

9. “Depending on which merchant you choose to use your mySource card at, may or may not necessitate the need to submit a claim form...”

10. Welcome to myRSC- Your Resource Service Center!

11. 1 2 1.Once you select the Reimbursement tab, you see your account information. 2.To view detailed information, click the detail link in box 2.

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13. View Accounts Including detailed account and balance information. SnapClaim File a claim and upload receipt photos directly from your Smartphone. Debit Card Activity View all debit card transactions and account activity. Manage Subscriptions Set up email notifications to keep you up-to-date on all account and health debit card activity. Locating and Loading the Mobile myRSC App Simply search for "myRSC" on the App StoreSM for Apple products or on the Google Play™ Store for Android products, and then load as you would any other app Logging In Use the same username and password you use to log in to the full myRSC website. After logging in, you will be on the home page which will list your options

14.  O.C.A. Customer Service Line: ◦ 609-514-0777  Mail Claims to: ◦ 3705 Quakerbridge Rd. Suite 216, Mercerville, NJ,08619  Email claims to: ◦ claims@oca125.com claims@oca125.com  Fax claims to: ◦ 609-514-2778