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© Hitesman & Wold, P.A. 2019 Cafeteria Plan Summary Description (3-11) 51 (i) At any 90% pharmacy if the expense is substantiated after the purchase in accordance with paragraph (7) 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 pharmacist; (B) the pharmacist assigns a prescription number and dispenses the over- the-counter drug or medicine in accordance with applicable law; (C) the pharmacy retains a record of the transaction, including the name on prescription, prescription number, date, and the amount of the purchase; (D) the pharmacy’s records are accessible by the employer or its agent; (E) the debit card system does not allow over-the-counter drugs or medicines without a prescription number; and (F) the expense is substantiated in accordance with the standard rules described above in paragraphs (vii) and (viii). (iii) At merchants having healthcare related merchant codes (other than merchants described in item ii above) if the expense is substantiated in accordance with the standard rules described above in paragraphs (vii) and (viii). Note: If the over-the-counter medicine cannot be purchased with the electronic payment card, it may still be reimbursed using the ma nual reimbursement procedures described in paragraph (a) above. (10) You must pay back any improperly paid claims. If you are unable to provide adequate or timely substantiation as requested by the Claims Administrator within the applicable time period, the card will be turned off and you must repay the Plan for the unsubstantiated expense. The deadline for repaying the Plan is set forth in the Cardholder Agreement. If you do not repay the Plan within the applicable time period, then the amount of the improperly paid claim may be withheld from your pay (if allowed by applicable law) and/or offset against future eligible claims under the Health FSA. If the amount of the improperly paid claim is not collected in full as described herein, the remaining unpaid amount will be treated as an indebtedness to the Employer. (11) You can use either the payment card or the paper claims approach. You have the choice as to how to submit your eligible claims. If you elect not to use the electronic payment card, you may also submit claims under the paper claims approach discussed above. Claims for which the electronic payment card has been used cannot be submitted as paper claims. (12) Your use of the payment card is not a claim. The use of an electronic payment card does not constitute a “claim” under the claims procedures. 7.7 What limits apply to reimbursements under the Limited Scope Health FSA? You cannot be reimbursed for any expenses above the amount of your election. You also cannot be reimbursed for any expenses that were incurred before the effective date of the Limited Scope Health FSA, for any expenses incurred before you become a Participa nt in the Limited Scope Health FSA, or for any expenses incurred after you terminate employment or otherwise cease to be eligible for coverage under the Limited Scope Health FSA, unless coverage is continued.