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Total Rewards GuideThis guide is your one-stop-shop for information about the benefits

available to you – you can also visit the Total Rewards site in MyUltiStuff. Thank you for all you do to make Jack in the Box a great place to work!

Welcome to Your Fiscal Year 2021

You’re Here, We’re Glad!(Variable Hour - Restaurant Team Leaders and Team Members)

Great Options for You and Your FamilyAs part of the JACK family you have access to a wide range of benefits, including everything from pay, health and wellness, saving for retirement, paid time-off, and so much more! These are your Total Rewards - our way of showing you that YOU are important to us and we value all that you do. We are committed to providing market-competitive, quality benefits at the best cost possible with flexibility of choice to meet the changing needs of you and your family members.

For some of your benefits JACK pays the full cost or shares in the cost. If you enroll in voluntary benefits, you pay the full cost - we negotiate with providers to offer great group rates so that you pay less than what you would if you were to buy coverage on your own.

Here is what we offer:

Paying for BenefitsYour bi-weekly premium payments are made through payroll deductions - some are pre-tax and others are after-tax.

• Pre-tax benefits include premiums for Medical, Health Savings Account, and 401(k) contributions.

• After-tax benefits include premiums for Dental, Vision, Supplemental Life Insurance, MetLaw Legal Plan, and ROTH 401(k) contributions.

JACK pays largest portion of cost• Medical (for

ACA-benefit eligible)

JACK pays full cost• HSA Employer contributions (if

enrolled in a UHC Medical Plan)• Basic Term Life Insurance (for ACA-

benefit eligible)• Employee Assistance Program (EAP)

(Team Leaders only)• 401(k) Matching Contribution• Naturally Slim Wellness Program

YOU pay full cost • Dental• Vision• Supplemental Term Life Insurance• MetLaw Legal Plan• Pet Insurance

YOUR TOTAL REWARDS

NOTE: THIS GUIDE IS INTENDED AS A SUMMARY TO HIGHLIGHT THE KEY FEATURES OF YOUR TOTAL REWARDS PROGRAMS. THE OFFICIAL PLAN OR PROGRAM DOCUMENTS WILL GOVERN IN THE EVENT OF ANY DISCREPANCY WITH INFORMATION PROVIDED IN THIS GUIDE.

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TABLE OF CONTENTS

HEALTH AND WELLNESS

Medical 6Prescription Drugs (Rx) 10Wellness 11Dental 12Vision 13How to Enroll 14

Annual Open Enrollment 14Qualified Life Event (‘QLE’) 14

FINANCIAL WELLBEING

Health Savings Account (HSA) 15401(k) - Easy$aver Plus Plan 16Life Insurance 17Retirement Plan (Pension Benefit) 17Prudential Financial Wellness 18MetLaw Legal Plans 18Pet Insurance 18

LEARNING & DEVELOPMENT

Tuition Reimbursement 19Academic Alliances 19Scholarships 19

WORK / LIFE HAPPINESS

Paid-Time Off (Vacation, Sick) 20Employee Assistance Program (EAP) 21Leave of Absence (LOA) 21Discounts 21

PAY AND RECOGNITION

Base Pay 22

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HELPFUL TERMS TO KNOWAs you review your benefit plan options, knowing these terms will help you better understand how the plans work.

TERM DEFINITION

Beneficiary Person or persons you name to receive benefits in the event of your death.

Benefit Plan Year October 1 through September 30.

COBRAStands for Consolidated Budget Omnibus Reconciliation Act, which is the federal law that requires employers to allow for continued coverage through a group health plan for up to 18 months after losing eligibility in the group plan, on a self-pay basis.

Coinsurance Percentage of eligible health care expenses you pay after your deductible has been met.

Consumer Driven Health Plan (CDHPs)

Health insurance plan with lower premiums and higher deductibles, that is typically combined with a tax-advantaged Health Savings Account (HSA) that can be used to pay for eligible health care expenses. CDHPs give employees more control over their health care options.

Copay Fixed dollar amount you pay for a covered health care service at the time the service is provided; applies to Kaiser Plan.

Covered Service Health care services that the plan will cover in part or in full based on plan documents.

Deductible Amount you pay each plan year for covered health care services before the plan begins to pay benefits.

Eligibility Date Date you are eligible to participate in JACK benefits and enroll online through MyUltiStuff.

Effective Date Date your benefit coverage begins.

Evidence of Insurability (EOI)

Application process in which you provide information on the condition of your health or your dependent’s health to get certain types of insurance coverage.

Health Maintenance Organization (HMO)

Managed health care program where services are coordinated by a primary care physician (PCP), including referrals to specialists within the HMO network (i.e. the Kaiser Plan).

Health Savings Account (HSA)

Type of tax-advantaged savings account where you can contribute tax-free money to pay for qualified medical expenses.

In-Network Provider Any licensed doctors, hospital, lab, or other health care provider that has contracted to provide members with comprehensive services at discounted rates.

Out-of-Network Provider

Any licensed doctors, hospital, lab, or other health care provider that is not part of a provider network. Rates are typically higher than in-network providers.

Out-of-Pocket MaximumMaximum amount you will have to pay Out-of-Pocket in a plan year for covered health care services, including prescriptions. Once you reach the Out-of-Pocket maximum, the plan pays 100% of covered services.

Qualified Life Event (QLE)

A change in your life status such as marriage/divorce, having/adopting a baby, losing/gaining health coverage, that qualifies you to be eligible for a special enrollment period where you can enroll in health coverage outside of the Annual Open Enrollment period. You have 30 days after the event occurs to make benefit changes.

Premium Amount you pay for your selected benefit plans each bi-weekly pay period.

Preventive Care Routine health care, including screenings, check-ups, and patient counseling to prevent or discover illness, disease, or other health problems.

Reasonable & Customary (R&C)

Maximum amount the plan will pay for a service, based on what providers in that geographic area charge for similar services or supplies.

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HEALTH AND WELLNESS

Eligibility & Dependents

When you can enroll

Dependent Verification

You and your eligible dependents can enroll in medical benefits if you are ACA Benefit-Eligible, meaning you worked an average of at least 30 hours per week in the latest 12-month consecutive period (“measurement period”), this is considered full-time under ACA (you would have previously received notification from JACK that you are eligible for medical benefits).

Important: If you are currently enrolled in medical benefits, and you want to keep your medical benefits in the new plan year, you MUST ENROLL in benefits during annual open enrollment.

When enrolling your dependents, you must submit documentation to show that they meet the eligibility requirements (refer to the Eligibility Definitions and Required Documentation document on the Total Rewards site in MyUltiStuff).

It is your responsibility to make sure you only enroll family members who are eligible, and that you discontinue coverage when dependents are no longer eligible.

Eligible Dependents include:

Your Spouse or Domestic Partner

Children under age 26 (excludes their spouses, domestic partners, or children)

Unmarried Disabled Children Over Age 26 (if they fully depend on you for financial support and care, provided they became disabled before age 26)

New HiresWhen/if during the Benefit Plan Year you become ACA Benefit-Eligible based on your initial measurement period (from your hire date through 12 consecutive months), JACK will notify you via USPS mail. You can then elect to enroll in medical benefits within two-months from the date you became ACA Benefit-Eligible.

If you enroll, your coverage will begin on the first day of the month following your ACA Benefit-Eligible date. Coverage for your dependents begins the same day your coverage begins. If you do not enroll within 30 days of your effective date, you must wait until the next Annual Open Enrollment.

Annual Open EnrollmentEach year during our Active Open Enrollment, you will need to ENROLL or WAIVE medical coverage.

THERE IS NO CARRYOVER OF PRIOR YEAR ELECTIONS.

Qualifying Life Events

If you have a Qualifying Life Event, you must complete the Life Event in MyUltiStuff within 30 days of the event occurring, otherwise you will need to wait until the next annual open enrollment (see Qualifying Life Event for more information).

Enrollment Information

TYPE ELIGIBLE TO ENROLL COVERAGE BEGINS COVERAGE ENDS

New Hire – Data Become

ACA EligibleWithin two months from the date you became ACA Benefit-Eligible

First of the month following your two-month enrollment period (from ACA Benefit-Eligible date)

September 30 of each year

Example (March 21) March 21 – May 21 June 1 September 30

Annual Open Enrollment August of each year October 1 of each year September 30 of each year

Benefits Plan Year 2020-2021 August 3 - August 17 ( 8:00 AM PT - 5:00 PM PT) October 1, 2020 September 30, 2021

Take some time to look closely at your medical plan options so that you choose the plan that best meets your needs. You can choose to enroll in one of three consumer-driven health plans (CDHP) administered by UnitedHealthcare (UHC), or the HMO plan (if you live in Southern California) administered by Kaiser Permanente.

There are three levels of UHC plans: Gold, Silver and Bronze, which are combined with a health savings account (HSA). Each of the UHC plans has different premiums, and in-network/out-of-network deductibles, coinsurance, and out-of-pocket maximums.

During the benefit plan year, you pay the full cost of non-preventive medical services until you reach the deductible. Once the deductible is met, you and JACK each pay a certain percentage of the cost of services (coinsurance), up to an out-of-pocket maximum. Any costs above the out-of-pocket maximum are then paid by JACK.

JACK contributes to your HSA account each bi-weekly pay period. You also have the option to contribute pre-tax dollars to your HSA through bi-weekly payroll deductions. Your HSA money can be used on qualified medical expenses or you can

The Kaiser Permanente Plan is only available to employees who live in Southern CA. With the HMO, you must use a provider in the Kaiser network. You pay a copay for almost all of your health care services – if you use services outside of the Kaiser network, you will not be covered unless it’s an emergency.

First you meet the Plan Year Deductible, if required

Then you pay Coinsurance (UHC Plans) or Copays (Kaiser)

After your Out-of-Pocket Maximum is met, the Plan pays 100%

UHC Bronze Plan (*) w/HSA

Kaiser HMO PlanSo-Cal Only

UHC Silver Plan w/HSA

UHC Gold Plan w/HSA

Bi-Weekly Premium Cost

How the Plans Work

UnitedHealthCare Medical Plans

Kaiser Permanente Medical Plans

Lowest Highest

Affordability*

The Patient Protection and Affordable Care Act (ACA) requires that we offer a plan where premiums for employee-only coverage doesn’t exceed 9.86% of your household income. Our UHC Bronze Plan meets this requirement.

MEDICALChoosing your Plan

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Preventive care services are covered 100% and are not subject to the plan deductible if performed on an outpatient basis at a physician’s office, an alternate facility or hospital. Preventive care includes routine health exams, screenings, and immunizations that are safe and effective in the early detection and prevention of disease and other health problems. Make sure to ask your health care provider if the services you need are preventive.

When you enroll in the UHC or Kaiser plans, you will receive a Medical ID card that is used for both medical and prescription drug benefits. Your card(s) should arrive in the mail within 5-7 business days of your effective date of coverage. For your convenience, within 24 hours of your effective date of coverage, you can also download their app to view/print your digital ID card on the UHC and Kaiser websites.

Note: Family coverage applies to Employee + Spouse/Domestic Partner, Employee + Children, and Employee + Family Coverage Levels

Preventive Care Medical ID Card

Important information about deductibles and Out-of-Pocket maximums for the UHC plans

Helpful Tips to Manage Your Claims Cost (UHC Plans)

Things to Consider when Selecting your Medical Plan

1. Use in-network doctors and facilities – remember, deductibles and Out-of-Pocket maximums for in-network and out-of-network must be met separately. In-network costs will not be applied to the out-of-network deductible or Out-of-Pocket maximums.

2. Compare doctor and facility costs - Visit myuhc.com to compare costs of doctors and facilities in your area. 3. Use the emergency room only for serious or a life-threatening emergency – they are the highest cost.4. Virtual Visits (cost approximately $50 or less) – Use online Virtual Visits whenever possible to see and talk to a doctor via mobile

device or computer – 24/7, no appointment needed. To learn more or get started with a Virtual Visit, go to myuhc.com/virtualvisits or to the UnitedHealthcare app.

1. How often do you go to the doctor and use the medical plan2. What do you anticipate your medical needs will be in the new plan year3. Do you primarily use the plan for preventive services4. Do you take regular prescriptions5. Do you prefer to have more money coming out of your paycheck and pay less when you go to the doctor’s office, or would you rather

pay less per pay check with higher out-of-pocket expenses?

UHC Bronze & UHC Silver Plans“Embedded”

UHC Gold Plan“Non-Embedded”

Per Person AND Family Deductible and Out-of-Pocket Maximum

Employee-Only OR Family Deductible and Out-of-Pocket maximum

Deductible

• Once a Person meets the Individual deductible, co-insurance applies for that person, even if the Family deductible has not been met.

• Once the Family deductible is met (by two or more family members), co-insurance applies for all family members.

• For Employee-Only coverage, once the employee-only deductible is met, co-insurance applies.

• For Family coverage, once the family deductible is met (by one or more family members), co-insurance applies for all family members.

Out-of-Pocket Maximum

• Once a Person meets the Individual Out-of-Pocket maximum, the plan pays 100% for that person, even if the Family Out-of-Pocket maximum has not been met.

• Once the Family Out-of-Pocket maximum is met (by two or more family members), the plan pays 100% for all family members.

• For Employee-Only coverage, once the employee-only Out-of-Pocket maximum is met, the plan pays 100%.

• For Family coverage, once the family Out-of-Pocket maximum is met (by one or more family members), the plan pays 100% for all family members.

Be sure to compare plan deductibles, coinsurance, out-of-pocket maximums, and premium payments.

MEDICAL BENEFITSBenefit Plan Year October 1, 2020 - September 30, 2021

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In & Out-of-Network Benefits UHC Plans w/Health Savings Account (HSA)(UnitedHealthcare Network)

HMO(Kaiser)

Medical Plans UHC Bronze UHC Silver UHC Gold Kaiser (SoCal Only)

Preventive Care Plan Pays 100% Plan Pays 100% Plan Pays 100% Plan Pays 100%

In/Out-of-Network In Out In Out In Out N/A

Annual DeductibleAmount you must pay Out-of-Pocket (for Rx and other covered services) before the plan begins sharing the cost.

$3,500 (I)$7,000 (F)

$7,000 (I)$14,000 (F)

$2,800 (I)$5,600 (F)

$5,600 (I)$11,200 (F)

$1,900 (I)1

$3,800 (F)$3,800 (I)1

$7,600 (F) None

Out-of-Pocket MaximumThe most you’ll pay Out-of-Pocket in the plan year.

$6,550 (I)$13,100 (F)

$13,100 (I)$26,200 (F)

$5,000 (I)$10,000 (F)

$10,000 (I)$20,000 (F)

$3,500 (I)1

$7,000 (F)$7,000 (I)1

$14,000 (F)$2,500 (I)$5,000 (F)

CoinsuranceThe percentage you pay of covered services after your deductible is met.

You Pay 40%

You Pay 50%

You Pay 25%

You Pay 50%

You Pay 20%

You Pay 50%

Copay$25 Primary Care

visit$35 Specialist visit

Company HSA Contribution $500 (I)$1,000 (F) N/A

Maximum 2021 HSA Contribution

$3,600 (I) / $7,200 (F)$1,000 catch-up for

those 55+N/A

Bi-Weekly Employee Premium

Coverage LevelsEmployee-OnlyEmployee + Spouse / DP2

Employee + Child(ren)Employee + Family

$38$87$73

$120

$54$123$103$169

$88$203$169$278

$98$225$186$311

Rx Retail & Mail Order3

GenericPreferred BrandNon-Preferred Brand & Specialty

You pay 20%You pay 40%You pay 50%

Refer to Summary of Benefits & Coverage

(SBC)

If you need additional information or details about the medical plans that are not covered in this guide, please refer to (a) the Summary of Benefits and Coverage (SBCs) and (b) Summary Plan Description (SPDs) available in MyUltiStuff, Total Rewards site under the Documents & Contacts tab.

Additional Resources for Medical Plans

I = Individual F = Family (yourself + 1 or more dependents)1 For the Gold Plan, Individual Annual Deductibles and Individual Out-of-Pocket Maximums apply to Employee-Only coverage level.2 DP = Domestic Partner3 Mail Order only for In-Network

MEDICAL BENEFITSMEDICAL PLANS AT A GLANCE

ADDITIONAL MEDICAL BENEFITS

2nd.MD – Second Opinion Program (UHC Members only)

2nd.MD is a great benefit that gives you the opportunity to get second opinions on medical diagnosis and treatment for you and your dependents.

Through the 2nd.MD website you will be connected via face-to-face online video or phone consultation with board-certified, leading doctors for an expert medical second opinion. 2nd.MD will coordinate all the details like collecting your pertinent medical records and imaging.

2nd.MD believes that a second opinion or a second viewpoint can change the course of someone’s treatment or life. They have the ability to support your treatment plan, regardless of how rare or challenging, so you can focus on one thing - getting the best care possible.

To get started go to www.2nd.md/activate or call 2nd.MD directly at 1-866-841-2575.

Virtual Visits (UHC Members Only)

What if you didn’t have to leave the house when you were sick?

With Virtual Visits, you can talk to a nurse or doctor from the comfort of your own home or from wherever you happen to be when you need care. And it’s simple!

To learn more or get started, go to myuhc.com/virtualvisits or on the UnitedHealthcare® app.

How it works

Answer a few questions about your health habits and fill out a brief Medical History.

Request a Virtual Visit and provide a few details about how you’re feeling.

Talk to a doctor by phone or video and get a prescription if necessary.

Virtual Visits & 2nd.MD

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When you enroll in a UHC medical plan, you are automatically covered under the prescription drug program administered by OptumRx. Kaiser administers the prescription drug benefit for the Kaiser medical plan.

Note: If you (and/or your dependents) have Medicare or will become eligible for Medicare during the benefit plan year, federal law gives you more choices about your prescription drug coverage. When you (and/or your dependents) become eligible for Medicare, information regarding Medicare Part D will automatically be sent to you by the medical plan.

Both the UHC and Kaiser plans have a list of prescription drugs, called a ‘formulary’ drug that’s considered a “preferred choice” based on its effectiveness and cost.

Type UHC Plan Kaiser Plan

PharmacyRetail: 31-day supplyMail Order: 90-day supply

Retail: 30-day supply Mail Order: 90-day supply

Generic You pay 20% after deductible You pay $10/prescription You pay $20/prescription

Preferred Brand Name You pay 40% after deductible You pay $30/prescription You pay $60/prescription

Non-Preferred Brand Name You pay 50% after deductible You pay $30/prescription You pay $60/prescription

Specialty

You pay 50% after deductible AND you are partnered with a Patient Care Coordinator to assist with medication schedule/delivery

You pay 20% of cost, up to $150 Not Available

More Information www.optum.com/optumrx855-828-9835

www.kp.org/formulary

For english: 800-464-4000

For spanish: 800-788-0616

The cost of your prescription depends on the type of drug you’re taking. Most prescriptions fall into one of three categories:

1. Generic: These are low-cost alternatives that are just as safe and effective as their brand-name equivalents. Choosing generics saves you money, so it’s a good idea to ask your doctor to prescribe a generic alternative when one is available.

2. Preferred Brand Name: These brand name drugs are preferred under the plan’s formulary for their effectiveness and value. They have lower copays than their non-preferred brand-name alternatives.

3. Non-Preferred Brand Name: These brand-name drugs are not preferred under the plan’s formulary. You pay the full cost for these drugs.

Prescription Drug Categories

PRESCRIPTION DRUGS (RX)Included with your UHC Medical Plan

Maternity Support(UHC Members Only)

To promote a healthy pregnancy and birth of your child, JACK will give you up to $300 for completing important milestones in the maternity support program offered by UHC and Kaiser.

Upon completion and verification of each important milestones in the program, you can receive up to three credits of $100 that will be applied to your bi-weekly medical premium:

• First Prenatal visit within the first trimester, • At the end of your second trimester, • Your baby’s birth.

WELLNESS

(UHC Members Only)

Ever wonder how some people can eat all their favorite foods and not gain weight? Naturally Slim is an online program that will teach you how.

There will be four times during the plan year that you can enroll in the program. The first opportunity will be from September 7th thru September 18th, 2020, with the program starting on October 5, 2020. If you don’t make it into the first session, you still can join later in the year.

To get started, go to www.naturallyslim.com/jack.

(UHC Members Only)

Rally is designed to help you make changes to your daily routine, set smart goals and track your progress. You’ll get personalized recommendations to help you move more, eat better and improve your health - and have fun doing it.

Plus, on Rally there are lots of ways to earn Rally Coins, which you can use for chances to win rewards.

Get started today at www.myuhc.com

*This program is offered at no cost to you if you are enrolled in one of the UHC plans, which includes your covered spouse and dependents over age 18.

Free Programs to Keep You Healthy and Well

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Who doesn’t want a great SMILE? You can have one by focusing on your overall dental health through regular dental care. Our dental plan, administered by Ameritas, provides coverage for preventive and restorative treatments.

Preventive dental care is an important part of an overall healthy lifestyle. To encourage regular preventive care, preventive services like cleanings and check-ups are not subject to the deductible and are paid at 100% by the plan.

When you need dental care, you have two options:• Network Dentists. This option is your best value for dental care. Network dentists are a select group of providers within

Ameritas’ network that have agreed to provide services to plan members at discounted rates. You have no claim forms to fill out when you go to a network dentist.

• Out-of-Network Dentists. If you choose to use a dentist who is not in the Ameritas network, the plan will pay up to the reasonable and customary (R&C) charges for a particular service in a particular area. If your out-of-network dentist charges are more than the R&C charge, you will have to pay the difference.

Coverage Type In-Network Out-of-Network1

Type A: PreventiveCleanings, Exams, X-rays 100%, no deductible 100%, no deductible

Type B: Basic RestorativeFillings, Extractions, TMJ You pay 30%, after deductible You pay 30%, after deductible

Type C: Major RestorativeBridges, Dentures, TMJ You pay 60%, after deductible You pay 60%, after deductible

DeductibleIndividual / Family $50/$150 $50/$150

Annual Maximum Benefit $1,000 per person $1,000 per person

Tier Bi-Weekly Employee Premium

Employee-Only $7.96

Employee+Spouse/Domestic Partner $15.92

Employee+Children $17.45

Employee+Family $25.40

Find a DentistTo find a network dentist, visit https://explore.ameritas.com/jib and select FIND A PROVIDER, then DENTAL. Enter your criteria to search by location or for the specific dentist or practice. For California Residents: When prompted to select your network, choose the Ameritas Network found on your ID Card or contact Customer Connections at (800) 487-5553.

1R&C: Reasonable & Customary Charge

DENTAL

Ameritas is our dental plan administrator beginning October 1, 2020. You will need to provide your dentist with new insurance information once you receive your ID card from Ameritas.

Plans and Premiums

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The VSP+Affiliates vision plan helps reduce the cost of vision exams, eyeglasses, contact lenses and other vision services. If you use a VSP network provider, you receive high quality vision care at the lowest Out-Of-Pocket costs and receive allowances or discounted rates on other services.

VSP (through Ameritas) is our new vision plan administrator beginning October 1, 2020. Once you enroll in vision benefits, make an appointment with your provider and let the provider know that you have VSP+Affiliates insurance coverage. They will verify your coverage and eligibility before you arrive for your appointment. There is no vision ID card necessary.

Benefit In-Network Frequency

Well Vision Exam $10 copay Every 12 months

Prescription Glasses $130 allowance, after $25 copay Frames: Every 24 monthsLenses: Every 12 months

Contacts (Instead of glasses)$60 copay

$130 allowance (elective lenses)Every 12 months

Diabetic Eyecare Plus $20 copay As needed

Tier Bi-Weekly Employee Premium

Employee-Only $1.95

Employee+Spouse/Domestic Partner $3.50

Employee+Children $3.60

Employee+Family $5.50

Find a Vision ProviderTo find a VSP provider, visit their website at https://explore.ameritas.com/jib/vsp-vision/ or call (800) 877-7195.

VISIONPlans and Premiums

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HOW TO ENROLL

1. Go to www.myultistuff.com from your desktop, laptop, tablet or mobile device. Note: If you are accessing MyUltiStuff using your Mobile device (Apple iPhone/Android) select View Desktop Version at the bottom of the login screen.

2. Enter your USERNAME and PASSWORD then select Log In.3. In the Total Rewards box, click the Total Rewards Wheel. 4. Enter PASSWORD ‘jack’ and hit SUBMIT. 5. On the next screen, click ADMIN 6. Navigate to the Health & Wellness section to review information on the new plans.7. Once you are ready to enroll, select Enroll Now on the left side of the page. 8. Once back in MyUltiStuff, depending on the nature of your enrollment, follow one of the paths below:

WWW.MYULTISTUFF.COM

QUALIFIED LIFE EVENTS (QLE)Make changes to your benefit coverage during the Plan Year

Dependent Coverage Start Date

Submitting a QLE in MyUltiStuff

A qualified life event is a change in your situation that meets one of the criteria listed below. Having a QLE can make you eligible for a Special Enrollment Period, allowing you to enroll or make changes to your health insurance outside the Annual Open Enrollment Period. All changes must be completed through the Life Event in MyUltiStuff within 30 days of event occurring, otherwise you will need to wait until the next Annual Open Enrollment.

• Spouse or Domestic Partner – coverage is effective the first of the month following the date of your marriage or domestic partner registration.

• Newborn/Adopted Child – coverage is effective on the date of the birth or adoption.

1. Log in to www.myultistuff.com

2. Select Menu > Myself > Life Events

3. On the Life Events page, select the QLE that applies and submit.

4. For approval, supporting documentation must be sent to benefits@jackinthebox.com If you are unable to provide the documentation to validate your life event, you will need to wait until our next Annual Open Enrollment.

Examples of Considered Life Events

Getting married, legally separating, or getting divorced

Having a change in your, your spouse’s, or domestic partner’s employment status

Registering a domestic partner Losing a dependent through death or loss of legal custody

Having a baby or adopting a child or obtaining legal custody of a child

Moving to an area where your current plan may not be offered (Kaiser SoCal).

A child who reaches the coverage age limit (26) and losing coverage through a parent’s plan

Becoming eligible for Medicare

IF YOU ARE A NEW HIRE:Select Menu > Myself > Life Events > New Hire Enrollment

DURING ANNUAL OPEN ENROLLMENT:Select Menu > Myself > Open Enrollment

FINANCIAL WELLBEING

Health Savings Account(UHC Members Only)

If you enroll in a UHC plan, it includes a Health Savings Account (HSA). An HSA is a great way to save for current and future healthcare-related expenses, all while lowering your taxable income - and it grows tax-free! It is an important part of your retirement savings.

OptumBank is the HSA plan administrator. You can access your account at optumbank.com or through myuhc.com.

Key Features

Important Information

JACK contributes to your HSA each bi-weekly payroll (annual amount ÷ 26 pay periods) = $19.23 (Individual) or $38.46 (Family) bi-weekly.

YOU can contribute to your HSA through bi-weekly payroll deductions – you can enroll or make changes at any time through the Life Event in MyUltiStuff.

Money in your HSA is not taxed when you put it in your account (CA residents: subject to state income tax). To receive/make contributions, you must activate your HSA account through OptumBank.

Money in your HSA is yours – what you do not use rolls over year-over-year. Your HSA is portable, which means if you leave JACK you take your HSA funds with you

For calendar year 2021, you can contribute up to $3,600 as an Individual or $7,200 for yourself + 1 or more dependents. If you’re age 55+, you can contribute $1,000 in catch-up contributions. Contact benefits@jackinthebox.com to set up your HSA Catch-Up contribution. Make sure to include any employer contributions amounts towards your annual limits.

Your contributions are Triple Tax-Advantaged:

No federal tax on money contributed from each paycheck | No federal tax on interest or investment earnings | No federal tax on money used to pay for eligible health care expenses.

Note: If you are age 65+ and enrolled in Medicare, you cannot make contributions into an HSA, or receive employer contributions.

Health Savings Account (HSA)

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FINANCIAL WELLBEING401(k) - Easy$aver Plus Plan

401(k) Plan - Easy$aver Plus PlanThe 401(k) Plan helps you build financial security for your future. At JACK we offer the opportunity for you to make both pre-tax and post-tax (Roth) contributions, and JACK matches your contribution after one year of service, dollar for dollar up to 4%of your eligible compensation. Charles Schwab administers the plan. The plan year for the 401(k) is based on a calendar year.

EligibilityYou are eligible to participate in the 401(k) on the first day of the calendar quarter following your date of hire. You must be at least age 21 to participate. When you become eligible, enrollment materials be mailed to your home by Charles Schwab.

InvestmentsYou can choose from a variety of investment funds available in the plan, or a Target Date Fund which is a blend of stocks, bonds and short-term investments in a single fund that is allocated based on the year you plan to retire. You can change your investments at any time.

ContributionsYou may contribute up to 30% of your eligible compensation to your 401(k) account (up to the IRS annual limits established for the calendar year – $19,500 for 2020). If you are age 50 or older, or will turn 50 during the calendar year, you are eligible to make an additional $6,500 “catch up” contribution.

Your pre-tax contributions are not taxed until they are distributed from the Plan, which means you have less taxable income in the year you contribute to the 401(k). You can change, stop or start contributions at any time.

Additionally, you can make a separate election to contribute a portion of your annual (or quarterly) bonus into the plan. This allows you the flexibility to contribute more to your retirement savings when you receive extra income, while keeping your contributions from your regular pay at a comfortable level.Your contributions and JACK’s matching contributions to your 401(k) account are always 100% vested, meaning “you own it.”

How to EnrollEasy One Click Enrollment—With the push of a button, you can enroll in the Plan at a 4% rate with your contributions invested in a Target Date Fund based on your age.Easy enrollment is available two ways:• Web: workplace.schwab.com• Schwab Workplace Retirement App: workplace.schwab.com/mobile

If you enroll online, select Register Now and follow the prompts to create your online login. Once you’re enrolled, you can make changes to your contribution rate and investment elections at any time.

Prefer to Make Your Own Elections?Once you are logged in to your account, select Manage Account > Contributions to choose your own contribution rate and investment elections when you enroll via workplace.schwab.com or the mobile app.

If you prefer, you can also enroll by calling 800-724-7526 (877-905-2553 para Español) to speak with Participant Services. Representatives are available from 7 a.m. to 11 p.m. ET, Monday through Friday.

FINANCIAL WELLBEINGLife Insurance & Retirement Plan

JACK wants to make sure you and your family are protected in the event of your death. We offer the following life insurance plans. Coverage is provided through Reliance Standard and rates are available in the Total Rewards site in MyUltiStuff.

Plan What you need to know

Basic Term Life Insurance

• If you are ACA Benefit-Eligible, you are automatically covered at $5,000, paid by JACK.• An accelerated death benefit allows you to receive a portion of your life insurance in advance if you become

terminally ill. If you take a portion of your money, your beneficiary will receive the remaining balance.

Supplemental Term Life Insurance

• You pay the full cost for this coverage.• You can purchase coverage in the amounts of $10,000, $20,000 and $30,000.• You are eligible to enroll for coverage within 30 days following one month of service (30 days from your hire

date) – “benefit-eligible.” If you don’t enroll when you first become “benefit-eligible,” Evidence of Insurability (EOI) will be required if you decide to enroll or change coverage at a later date.

• An accelerated death benefit allows you to receive a portion of your life insurance in advance if you become terminally ill. If you take a portion of your money, your beneficiary will receive the remaining balance.

• Bi-weekly premium coverage rates are age-banded per the sheet below.

Benefit Amount

Age 18-24

Age 25-29

Age 30-34

Age 35-39

Age 40-44

Age 45-49

Age 50-54

Age 55-59

Age 60-64

Age 65-69

Age 70+

$10,000 $0.14 $0.17 $0.23 $0.25 $0.28 $0.42 $0.65 $1.21 $1.86 $3.57 $5.79

$20,000 $0.28 $0.34 $0.45 $0.51 $0.56 $0.84 $1.29 $2.42 $3.71 $7.14 $11.58

$30,000 $0.42 $0.51 $0.68 $0.76 $0.84 $01.26 $1.94 $3.63 $5.57 $10.72 $17.38

Retirement Plan (Pension Benefit)Pension benefits are offered to eligible employees hired prior to January 1, 2011 that had reached age 21 and completed one year of service (minimum of 1,000 hours). If eligible, the amount of your retirement benefit is based on your earnings and years of service as of December 31, 2015. • Benefits cannot be paid while you are actively employed by JACK• To be eligible for a benefit, you must complete five years of service• Normal retirement age is either 62 or 65, depending on years of service• Benefits are typically paid in the form of a monthly annuity upon retirement• At retirement, you can select from an option of payment methods

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FINANCIAL WELLBEINGWork/Life Benefits

Prudential Financial WellnessNowadays, many of us are facing unique financial challenges and it can be difficult to know where to turn for help. JACK recognizes that the day-to-day stress these challenges create can be harmful to our health and our relationships. That is why we have partnered with Prudential to give you the tools and resources you need to feel inspired and empowered to help improve your financial wellness.

Financial wellness is the ability to manage short-term finances while also saving for long-term goals. No one has the same financial wellness needs as you do. That’s why Prudential’s Financial Wellness Center combines digital learning and interactive tools with personalized content to help you take action.

Whether you need to create a budget, manage student loan debt or save for a big purchase, Prudential can help! Get started today by going to www.prudential.com/jack. Create your profile and use the Self-Assessment Tool to identify where to focus first. No matter where you are on your financial journey, it’s never too late to get started!

MetLaw Legal PlansMetLaw, provided by Hyatt Legal Plans provides comprehensive legal assistance to you and your eligible dependents.

Eligibility / Enrollment• You can enroll in the Plan if you meet the same eligibility requirements for the medical/dental/vision plans. • You can only enroll or make changes during Annual Benefits Open Enrollment – your elections will carry over year to year.• New Hires can enroll within 30 days following 30 days of service from hire date. • Important: You cannot stop or start coverage during the year as a result of a qualifying life event (QLE).

If you terminate employment or retire, you have the option to convert your legal plan for a 30-month period, by enrolling in the portable plan within 30 days of your last day of employment by calling Client Service Center at 800-821-6400. Conversion does require that you pay the full 30-month commitment at the group rate prior to enrollment.

Low Plan: $3.81/pay period Website Access Code: 9902525

High Plan: $8.54/pay period Website Access Code: 9902523

Services Available

While benefits are comprehensive, there are some limitations and conditions that apply for certain services, in addition to some excluded services. Covered services include:

• Services available in both the High and Low Plans, include:• Identity Theft, Negotiations with creditors,

Promissory Notes, and Debt/Tax Collection• Deeds, Mortgages, Foreclosure, Eviction, Security

Deposit• And more!

• Services only available in the High plan include:• Tax Audit Representation, Bankruptcy• Home Loans, Sales and Purchases, Property Tax• Trusts• Immigration Documents

For additional information, go to the Total Rewards site on myultistuff.com or visit info.legalplans.com and enter the website access codes(s) above or call the Client Service Center at 1-800-821-6400 M-F 8am-8pm (Eastern Time).

Pet InsuranceJACK is pleased to offer a new benefit beginning plan year 2020/2021, My Pet Protection® from Nationwide. All of our pet lovers can now take advantage of preferred pricing options that are exclusive to JACK employees. We all spend a lot of time with our four-legged fur babies and we want to make sure they are healthy and protected too!

You can choose from 3 different levels of reimbursement to get cash back on eligible vet bills. You’ll pay the same price no matter what age your pet is, and the rate will never go up because they get older.

To learn more about this benefit and get a quote go to http://benefits.petinsurance.com/jack.

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LEARNING & DEVELOPMENT

Tuition Reimbursement (Team Leaders only)If heading to school can help prepare you for the next steps in your career, with JACK or wherever your dreams take you, we want to help support you with our Tuition Reimbursement Program.

Eligibility • Must have at least 6 months of continuous service working 40 hours per week. • All classes must be pre-approved prior to the start of the course.• You must maintain satisfactory performance to enter and remain in the program. • Must be employed by JACK when the course is completed and when reimbursements are made.

What is Reimbursed • Maximum reimbursement is $4,000 per calendar year. • Reimbursement includes 100% of fees for tuition, registration and books• Reimbursement amounts are based on the calendar year in which they are disbursed.

Ready to get started? Check out the Tuition Reimbursement Policy and fill out your Pre-Approval Form today!

Scholarships (Team Members Only)Jack in the Box encourages Team Members to pursue their education and their dreams. To help employees reach their goals Jack in the Box awards scholarships to deserving team members. Twice a year, $500 scholarships are awarded to 20 Team Member recipients.

Eligibility • Must have at least 6 months of continuous service and working a minimum of 25 hours per week. • Be enrolled at an accredited institution for an undergraduate degree, graduate degree or certificate program. • Submit a completed application with required attachments by the due date. Applications with dates and program information will be

sent to each restaurant (typically in Q1 and Q3 of the fiscal year). • The program administrator determines if an institutions accreditation is acceptable and if a certificate program is approved.

Academic AlliancesJACK has formed alliances with several universities to offer you tuition discounts and scholarships to some of the most sought-after degree programs. Discounts are being offered from these partnerships:

Additional information can be found on the Total Rewards site through MyUltiStuff. Each program has its own enrollment process; if you’re interested in taking advantage of these discounts, please contact the school or university directly.

Helping you prepare for the next steps

Capella University University of Phoenix Alliant International University Colorado State University

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Vacation TimeYou are eligible for vacation benefits after you have worked for JACK for 180 days.

• You receive vacation hours for each week (Monday – Sunday) that you work at least 30 hours. • Year 1: receive .57 hours per week• Year 2 or more: receive 1.15 hour per week

Note: if you work less than 30 hours in a week, you don’t receive any vacation hours for that week.

• You can request a payout of any available hours whenever you need to use them or save them and get a larger lump-sum payment.

• The maximum hours you can have available at any time is:• Year 1: 45 hours• Year 2 or more: 90 hours

Note: once your available hours are at the maximum, you cannot receive any more vacation hours until you use some of your hours or request a lump-sum payment.

WORK/LIFE HAPPINESS

JACK encourages you to take time off away from work to take care of you and your family. This includes for vacation, personal appointments, illnesses, emergencies, and holidays. That’s why we offer you a variety of paid-time off – it’s important to your overall health and happiness!

Sick Time• You may receive sick hours if required in your state and/or local area.

HolidaysTeam Leaders and Team Members that work on Thanksgiving and Christmas day will receive pay at 1.5 times their regular rate of pay for hours worked.

Be sure to submit your time-off in MyUltiStuff prior to or within the same pay period you take time off.

Paid Time Off

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WORK/LIFE HAPPINESS

Employee Assistance Program (EAP - Team Leaders Only)Your personal and professional happiness and well-being is important to us. That’s why JACK has partnered with ComPsych Guidance Resources to provide you and your family with the EAP. The EAP provides confidential support, resources and information for personal and work-life issues. These services are provided at no cost to employees and are available 24/7.You and each household member can receive up to five free sessions per incident. In addition to on-line guidance resources, it includes:

Confidential Counseling – highly trained clinicians who will listen to your concerns and refer you to in-person counseling or other resources for stress, anxiety and depression, relationship/marital conflicts, problems with children, job pressures, grief and loss, and substance abuse.

Worklife Solutions – Work-life Specialists to provide qualified referrals and customized resources for child and elder care, moving, pet care, college planning, making large purchases and more.

Financial Information and Resources – Certified Public Accountants and Certified Financial Planners to answer questions about budgeting, paying off debt, tax questions, retirement planning and other financial issues.

Legal Support and Resources – On-staff licensed attorneys to speak with you about divorce and family law, landlord/tenant issues, debt and bankruptcy, contracts and more. If you require representation, you can be referred to a qualified attorney in your area for a free 30-minute consultation with a 25% reduction in customary legal fees thereafter.

To contact ComPsychCall 866-735-0703, or go online to www.guidanceresources.com and enter JACK’s company ID: jibeap

Leave of AbsenceJACK has partnered with Matrix Absence Management to administer all employee leave of absences (LOAs). Most leaves must be managed in compliance with federal and state regulations. If you need information or plan to take an LOA, reach out directly to Matrix, they can answer any questions and guide you through the process from the beginning of your LOA and through to your return to work.

To contact Matrix• Call (877) 202-0055, available 24/7, 365 days a year• Download the Matrix eServices mobile app• Go to www.matrixabsence.com

DiscountsPerkSpot gives you exclusive discounts on thousands of your favorite brands and items – everything from electronics, auto, travel, tickets, food and more!

Log into jib.perkspot.com to check out the list of discounts available!Get started at www.jib.perkspot.com.

Additional Programs

PAY & RECOGNITION

Base Pay• Your base pay is what you are paid on an hourly

basis. Payments are made bi-weekly via pay card, direct deposit, or other election.

• Pay ranges for team members are based on the minimum wage in place in the applicable city or state as well as external market data which provides the competitive rate for each position.

• Pay ranges for team leaders start at $1.00 over minimum wage.

• Actual pay should not be below range minimum or above range maximum.

Base Pay

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WHERE TO GO FOR INFORMATION

Plan Contact Number or Website Group Number

Health Plan Enrollment

• Enroll or change health plan selections• Add/delete dependents• Other life event changes

Benefits Departmentbenefits@jackinthebox.com

1-800-500-5225, Option 5 then 6www.myultistuff.com N/A

Medical Plans• Find a network provider• Check the status of a claim• Request an ID card• Confirm your eligibility or coverage

UnitedHealthcareGold Medical PlanSilver Medical Plan

Bronze Medical Plan

Kaiser Permanente Medical Plan (So-Cal only)

1-877-468-0979www.myuhc.com

1-800-464-4000www.kp.org

704025

Southern California104971-01

Dental Plans• Find a network provider• Verify coverage of a particular service• Check the status of a dental claim

Ameritas 1-800-487-5553https://explore.ameritas.com/jib 010-301923

Vision plan• Find a network provider• Find out how to use the plan• Get information about what’s covered

Ameritas 1-800-877-7195https://explore.ameritas.com/jib/vsp-vision/ 00103013

Health Savings Account (HSA) Optum Bank1-866-234-8913 Option 1

www.optumbank.comwww.myuhc.com

Policy Number:704025

Weight Management Program Naturally Slim www.naturallyslim.com/jacksupport@naturallyslim.com Jack

Life Insurance• Basic term life insurance• Optional term life insurance

Reliance Standard 1-800-351-7500www.RelianceStandard.com

Policy Number:GL157804

401(k) Easy $aver Plus Plan Charles Schwab 1-800-724-7526workplace.schwab.com N/A

Prudential Financial Wellness Prudential 800-778-4357www.prudential.com/jack N/A

Pet Insurance Nationwide 877-738-7874http://benefits.petinsurance.com/jack N/A

Leave of Absence (LOA) Matrix Absence Management

1-877-202-0055www.matrixabsence.com

Policy Number:704025

EAP• Free, confidential counseling and

referral service available 24/7• Work-Life solutions, legal support,

financial information• GuidanceResources Online

ComPsych GuidanceResources

1-866-735-0703www.guidanceresources.com

Company ID: JIBEAP

COBRA McGriff COBRA Services, Inc. 1-888-888-3442cobraadmin@mcgriffinsurance.com CBJAC281

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Benefits Program Required Legal Notices

Jack in the Box Inc. 9357 Spectrum Center Blvd.

San Diego, CA 92123 Prepared on 06/18/2019

As part of Jack in the Box Inc’s compliance obligations, Jack in the Box Inc. must provide certain legal notices to its U.S. benefits eligible employees.

THE REQUIRED DISCLOSURE

NOTICES INCLUDED WITHIN

THIS PACKET ARE:

• Medicaid and the Children’s

Health Insurance Program (CHIP) Notice

• Medicare Part D Notice • HIPAA Privacy and HIPAA

Special Enrollment Rights

• Summaries of Benefits and

Coverage (SBCs) • Women’s Health and Cancer

Rights Act • Newborns’ and Mothers’ Health

Protection Act of 1996 (Newborns’ Act)

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Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2020. Contact your State for more information on eligibility.

ALABAMA – Medicaid COLORADO – Health First Colorado (Colorado’s Medicaid Pro-gram) & Child Health Plan Plus (CHP+)

Website: http://myalhipp.com/

Phone: 1-855-692-5447

Health First Colorado Website: https://www.healthfirstcolorado.com/

Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plus

CHP+ Customer Service: 1-800-359-1991/ State Relay 711

ALASKA – Medicaid FLORIDA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/

Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com

Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: http://flmedicaidtplrecovery.com/hipp/

Phone: 1-877-357-3268

ARKANSAS – Medicaid GEORGIA – Medicaid Website: http://myarhipp.com/

Phone: 1-855-MyARHIPP (855-692-7447)

Website: https://medicaid.georgia.gov/health-insurance-premium-payment-program-hipp

Phone: 678-564-1162 ext 2131 CALIFORNIA – Medicaid INDIANA – Medicaid

Website: https://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspx

Phone: 1-800-541-5555

Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/

Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com

Phone 1-800-403-0864

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IOWA – Medicaid and CHIP (Hawki) MONTANA – Medicaid Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366

Hawki Website: http://dhs.iowa.gov/Hawki

Hawki Phone: 1-800-257-8563

Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP

Phone: 1-800-694-3084

KANSAS – Medicaid NEBRASKA – Medicaid Website: http://www.kdheks.gov/hcf/default.htm

Phone: 1-800-792-4884

Website: http://www.ACCESSNebraska.ne.gov

Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178

KENTUCKY – Medicaid NEVADA – Medicaid Kentucky Integrated Health Insurance Premium Payment Pro-gram (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx

Phone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.gov

KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx

Phone: 1-877-524-4718 Kentucky Medicaid Website: https://chfs.ky.gov

Medicaid Website: http://dhcfp.nv.gov

Medicaid Phone: 1-800-992-0900

LOUISIANA – Medicaid NEW HAMPSHIRE – Medicaid Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp

Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)

Website: https://www.dhhs.nh.gov/oii/hipp.htm

Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext 5218

MAINE – Medicaid NEW JERSEY – Medicaid and CHIP Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html

Phone: 1-800-442-6003 TTY: Maine relay 711

Medicaid Website: http://www.state.nj.us/humanservices/

dmahs/clients/medicaid/

Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html

CHIP Phone: 1-800-701-0710 MASSACHUSETTS – Medicaid and CHIP NEW YORK – Medicaid

Website: http://www.mass.gov/eohhs/gov/departments/masshealth/

Phone: 1-800-862-4840

Website: https://www.health.ny.gov/health_care/medicaid/

Phone: 1-800-541-2831

MINNESOTA – Medicaid NORTH CAROLINA – Medicaid Website:

https://mn.gov/dhs/people-we-serve/children-and-families/health-care/health-care-programs/programs-and-services/medical-assistance.jsp [Under ELIGIBILITY tab, see “what if I have other health insurance?”]

Phone: 1-800-657-3739

Website: https://medicaid.ncdhhs.gov/

Phone: 919-855-4100

MISSOURI – Medicaid NORTH DAKOTA – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

Phone: 573-751-2005

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/

Phone: 1-844-854-4825

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OKLAHOMA – Medicaid and CHIP UTAH – Medicaid and CHIP Website: http://www.insureoklahoma.org

Phone: 1-888-365-3742

Medicaid Website: https://medicaid.utah.gov/

CHIP Website: http://health.utah.gov/chip

Phone: 1-877-543-7669

OREGON – Medicaid VERMONT– Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx

http://www.oregonhealthcare.gov/index-es.html

Phone: 1-800-699-9075

Website: http://www.greenmountaincare.org/

Phone: 1-800-250-8427

PENNSYLVANIA – Medicaid VIRGINIA – Medicaid and CHIP Website: https://www.dhs.pa.gov/providers/Providers/Pages/Medical/HIPP-Program.aspx

Phone: 1-800-692-7462

Website: https://www.coverva.org/hipp/

Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282

RHODE ISLAND – Medicaid and CHIP WASHINGTON – Medicaid

Website: http://www.eohhs.ri.gov/

Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)

Website: https://www.hca.wa.gov/

Phone: 1-800-562-3022

SOUTH CAROLINA – Medicaid WEST VIRGINIA – Medicaid

Website: https://www.scdhhs.gov

Phone: 1-888-549-0820

Website: http://mywvhipp.com/

Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447) SOUTH DAKOTA - Medicaid WISCONSIN – Medicaid and CHIP

Website: http://dss.sd.gov

Phone: 1-888-828-0059

Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf

Phone: 1-800-362-3002

TEXAS – Medicaid WYOMING – Medicaid Website: http://gethipptexas.com/

Phone: 1-800-440-0493

Website: https://wyequalitycare.acs-inc.com/

Phone: 307-777-7531

To see if any other states have added a premium assistance program since January 31, 2020, or for more information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not dis-play a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respond-ent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Admin-istration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Wash-ington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.

OMB Control Number 1210-0137 (expires 1/31/2023)

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Important Notice from Jack in the Box Inc. About your Prescription Drug Coverage & Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Jack in the Box Inc. and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You

can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. Jack in the Box Inc. has determined that the prescription drug coverage offered by UnitedHealthcare and Kaiser is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th through December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

Medicare Part D Notice For employees enrolled in UnitedHealthcare and Kaiser.

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What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Jack in the Box Inc. coverage may be affected. You can keep this coverage if you elect Part D and this plan may coordinate with Part D coverage. If you do decide to join a Medicare drug plan and drop your current Jack in the Box Inc. coverage, be aware that you and your dependents may not be able to get this coverage back. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Jack in the Box Inc. and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage: Contact the person on the following page for further information.

NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Jack in the Box Inc changes. You also may re-quest a copy of this notice at any time.

Medicare Part D Notice

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For More Information About Your Options Under Medicare Prescription Drug Coverage: More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:

• Visit www.medicare.gov • Call your State Health Insurance Assistance Program (see the inside back cover of your

copy of the “Medicare & You” handbook for their telephone number) for personalized help • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

CMS Form 10182-CC Updated April 1, 2011 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

REMEMBER: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

Date: 06/19/2019

Name of Entity/Sender: Jack in the Box Inc.

Contact--Position/Office: Jack in the Box Inc Benefits Department

Address: 9357 Spectrum Center Blvd. San Diego, CA 92123

Phone Number: 1-800-500-5225, opt 5, opt 6

Medicare Part D Notice

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If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 30 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. If you wish to decline coverage for yourself or your eligible dependent(s), you will be required to complete the appropriate section on your election form. Please note that you or your dependent(s) must be enrolled in a benefit plan during the initial enrollment period in order to avoid being considered a Late Enrollee. You and/or your dependent(s) may qualify under a Late Enrollee Exception if you declined coverage during the initial enrollment period because you had other coverage under another employer’s medical benefits plan and coverage under that employer’s medical benefits plan ends. An employee or dependent who requests enrollment after the initial enrollment period will be considered to be a Late Enrollee unless the person qualifies under a Late Enrollee Exception. This is a brief statement regarding your HIPAA special enrollment rights and does not fully explain these rights. You should read the insurance carrier’s Summary Plan Description for a more detailed description of your HIPAA special enrollment rights.

HIPAA and Privacy Jack in the Box Inc. recognizes the confidentiality of you and your enrolled dependents’ personal health information, and we are committed to keeping that information private. In addition to our commitment, the Federal Health Insurance Portability and Accountability Act (HIPAA) establishes privacy rules for individually identifiable health information. For a copy of the privacy notice, please contact Jack in the Box Benefits at 9357 Spectrum Center Blvd., San Diego, CA 92123 or 1-800-500-5225, opt 5, opt 6

HIPAA Special

Enrollment Rights

HIPAA Privacy and Special Enrollment Rights

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As part of the Affordable Care Act (ACA), Summaries of Benefits and Coverage (SBCs) were created to provide easy-to-understand descriptions of the medical plan coverage available to you. They are designed to help you better understand, compare and evaluate your medical plan choices. You may find the SBCs for your medical plan choices as well as a helpful Glossary of Health Coverage and Medical Terms by going to the Jack in the Box Inc benefits portal at www.myultistuff.com and clicking on the Total Rewards wheel.

Paper copies of the SBCs may be obtained upon request from Jack in the Box Inc Benefits department.

Summaries of Benefits and Coverage (SBCs)

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In accordance with the Women’s Health and Cancer Rights Act of 1998 (“WHCRA”), your coverage under the Jack in the Box Inc. medical plans provides benefits for mastectomy-related services, including reconstruction and surgery to improve symmetry between the breasts, prostheses, and complications resulting from a mastectomy (including lymphedema). Our medical plans will not restrict benefits if: 1. You or your dependent received benefits for a mastectomy, and; 2. You or your dependent elected breast reconstruction in connection with the

mastectomy. Benefits will not be restricted provided that the breast reconstruction is performed in a manner determined in consultation with you or your dependent’s physician and may include:

• Reconstruction of the breast on which the mastectomy was performed

• Surgery and reconstruction of the other breast to produce a symmetrical appearance

• Prostheses and treatment of physical complications of all stages of mastectomy, including lymphedemas

If you would like more information on WHCRA benefits, please contact Jack in the Box Inc. Benefits at 1-800-500-5225, opt 5, opt 6 or visit https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/faqs/whcra.pdf Newborns’ and Mothers’ Health Protection Act of 1996 (Newborns’ Act) Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). If you would like more information on the Newborns’ Act, please contact Jack in the Box Inc. at 1-800-500-5225, opt 5, opt 6 or visit https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/fact-sheets/newborns-act.pdf

Women’s Health &

Cancer Rights Act Notice

Newborns’ & Mothers’ Health

Protection Act Notice

Women’s Cancer Rights and Newborns’ Act

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