Benefits GuideThis guide is your one-stop resource for Jack’s benefits.

To find additional information about the programs available to you, visit the Total Rewards site in MyUltiStuff.

Welcome To Your

Plan Year EffectiveOctober 1, 2019 - September 30, 2020

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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.

PHARMACY

Formulary List of prescription drugs covered by the health insurance plan and which coverage tier they fall under (i.e. generic, preferred, non-preferred).

Generic DrugPrescription drug that is equivalent to a brand-name drug with the same active (main) ingredients and is subject to the same FDA standards for quality, strength and purity. Generic drugs almost always cost less than brand-name drugs, although not all brand-name drugs have generic equivalents.

Preferred Brand Drug Prescription drug that is considered a “preferred choice” based on its effectiveness and cost.

Non-Preferred Brand & Specialty Drug

Prescription drug that isn’t on the Plan’s preferred list.

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Great Options for You and Your FamilyAt Jack in the Box Inc. (“JACK”), we recognize and value the contributions of each employee and remain committed to providing competitive benefits at the lowest cost possible with flexibility of choice.

As partners in taking care of your health and financial wellness, YOU and JACK each have a part. JACK provides a selection of quality health care plans and wellness resources for you and your family. YOUR part is to understand and choose the plans that best meet your needs and current situation.

Because health coverage is expensive, JACK pays the largest portion of the cost of core benefits. There are also some benefits offered to you on a voluntary basis, which means that if you enroll, you pay the full cost. We negotiate with the providers to offer great group rates, so even though you are paying the full amount, it is less than if you were to buy coverage on your own.

Here is what we offer:

What’s new for Plan Year 2019/20201. It’s important that each year you evaluate your benefit

options and choose plans that best meet your needs and current situation. That’s why we are moving to an “active” enrollment” process for the new benefit plan year, and going forward each year thereafter. This means there is NO CARRYOVER of your medical, dental and vision elections from one year to the next - EACH YEAR YOU MUST ENROLL or WAIVE COVERAGE in these health plans.

2. Working spouses can enroll in our medical plans even if they are eligible for medical benefits through their own employer. If your working spouse enrolls in their own employer’s medical plan, you still have the option to enroll your spouse in JACK’s dental and vision plans.

3. Be sure to read about the new voluntary benefit – MetLaw, provided by Hyatt Legal Plans. This Plan offers you and your family access to an affordable network of attorneys providing legal services.

4. The percentage of claims cost (coinsurance) that you pay once your deductible is met will decrease from 30% to 25% in the UHC Silver Plan.

Paying for BenefitsYour bi-weekly premiums are made through payroll deductions, some are pre-tax and others are after-tax. The benefit of paying premiums on a pre-tax basis is that you can save money because you pay less federal income and Social Security taxes, and in some states, state income tax.

• Pre-tax benefits include premiums for Medical, Dental, Vision, Health Savings and Flexible Spending Accounts, and pre-tax 401(k) contributions.

• After-tax benefits include premiums for Supplemental Life, AD&D, MetLaw Legal Plan, Short-term Disability, Long-Term Disability, and ROTH 401(k) contributions.

Core Benefits (Shared Cost)• Medical• Dental • Vision

Company-Paid Benefits (Full Cost)• HSA Employer contributions &

incentives• Basic Term Life Insurance• Business Travel Accident Insurance• Employee Assistance Program (EAP)• 401(k) Matching Contribution

Voluntary Benefits (You pay full cost)• Flexible Spending Account• Supplemental Term Life Insurance• Accidental Death & Dismemberment

(AD&D)• Disability Insurance (STD & LTD)• MetLaw Legal Plan

YOUR BENEFITS

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Note: When enrolling your dependents, you will be required to 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.

BENEFIT ELIGIBILITY AND COVERAGE

You and your eligible dependents can enroll for medical, dental, and vision coverage as long as you:• Are an Administrative or Clerical Employee (all

employees except restaurant Team Leaders and Team Members)

• Have worked at JACK for at least one month• Work at least 30 hours per week (130 hours per

month)

Eligible Dependents that can be enrolled in medical, dental, and vision coverage include:• Your Spouse or Domestic Partner• Unmarried or Married 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)

Eligibility Information Eligible Dependent Information

Things to Consider when Selecting your Medical Plan

How much do you want to have taken out of

each paycheck?Do you prefer lower

bi-weekly premiums with a higher deductible/Out-

of-Pocket maximum?Or, the other way around?

Do you take regular

prescriptions?

Compare plan deductibles,

coinsurance and Out-of-Pocket maximums.

How often do you go to the

doctor and use the plan?

What do you anticipate your medical needs to be in

the new plan year?

Do you primarily use the plan

for preventive services?

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HOW TO ENROLL OR WAIVE COVERAGE (MEDICAL, DENTAL AND VISION) DURING ANNUAL OPEN ENROLLMENTMonday, August 5, 2019 (8:00am PT) - Monday, August 19, 2019 (5:00pm PT)

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 USER NAME and PASSWORD and select Log In.3. If you are ready to enroll, select Menu > Myself > Open Enrollment from the

MyUltiStuff home page.4. If you would like to review information about the plans before enrolling, click on

the Total Rewards Wheel in the middle of the MyUltiStuff home page.5. Enter PASSWORD “jack” and hit SUBMIT.6. On the next screen, click ADMIN.7. Navigate to the Health & Wellness and Financial Wellbeing sections to review

information on plans offered this Benefit Plan year.8. Once you have reviewed information on the plans and you are ready to enroll,

return to the MyUltiStuff home page and select Menu > Myself > Open Enrollment.

WWW.MYULTISTUFF.COM

When Coverage is Effective following Annual Open Enrollment

When Coverage is Effective for New Hires

When Coverage Ends

Plan Year 2019/2020 Annual Open Enrollment

August 5 - August 19, 2019(8:00 AM PT) (5:00 PM PT)

Hire DateMarch 21

Eligible to Enroll in Benefits Online

April 21

Coverage EffectiveMay 1

Plan Year 2019/2020 Coverage Effective

October 1, 2019

Each year during Annual Open Enrollment you will need to choose to ENROLL or WAIVE medical, dental and vision coverage. There is no carryover of your prior year elections. Note: To prevent loss of medical coverage, if you are enrolled in a medical plan (for plan year 2018/2019) and do not enroll or waive medical coverage for the new plan year, you will automatically be enrolled in the UHC Bronze Plan (ACA-compliant) at the same coverage level as your current election.

If you enroll for benefits within 30 days following one month of service, your coverage begins on the first of the month following the date you become eligible (see example below). Coverage for your dependents begins the same day your coverage begins. If you do not enroll within 30 days of becoming eligible, you must wait until the next Benefits Annual Open Enrollment.

• Coverage ends on the last day of the plan year (for 2019/2020, it is September 30, 2020), OR• If you terminate employment with JACK, or you become ineligible for benefits due to a change in work schedule that is

below 30 hours per week (a “status change”), your coverage ends on the last day of the month of your termination date or status change date.

You may be eligible to continue coverage under COBRA (for medical, dental and vision plans). You have 60 days from the date on your COBRA election notice or from the loss of coverage date, whichever is later, to select coverage through COBRA. Information about COBRA (including your COBRA election notice) will be sent to you from McGriff COBRA Services (the company’s COBRA administrator) within 14 days from your termination or ineligibility date.

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

Dependent Coverage Start Date

Submitting a QLE in MyUltiStuff

Examples of Considered Life Events

You can only make changes during the plan year if you have a QLE that meets one of the criteria below; otherwise, you’ll have to wait until our next Annual Open Enrollment to make changes.

If you experience a QLE, submit the life event change through MyUltiStuff (instructions below) within 30 days of the change, and send supporting documentation to benefits@jackinthebox.com. For details on the type of supporting documentation needed, refer to MyUltiStuff > Menu > Life Events.

• 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.

• Step 1: Log in to www.myultistuff.com• Step 2: Select Menu > Myself > Life Events• Step 3: On the Life Events page, select the QLE that applies and submit. Documentation will be required.

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

Losing or gaining coverage through your spouse or a domestic partner

MEDICAL COVERAGEYou can choose to enroll in one of three UnitedHealthcare (UHC) plans, or the Kaiser HMO Plan (if you live in Southern California). Each of the medical plans includes pharmacy benefits (Rx). Each UHC plan (Bronze, Silver, or Gold) has different bi-weekly premiums, deductibles, coinsurance, Out-of-Pocket-maximums, and employer HSA contributions.

Be sure to review the key components of each plan in order to choose the right plan that is best for you and your family. Remember, the choice you make remains in place for the entire plan year (October 1, 2019 – September 30, 2020).

The UHC Gold, Silver, and Bronze Plans are consumer driven health plans (CDHP) with a combined savings opportunity through an HSA. Rather than paying higher premiums each pay period, you can pay less, and put the rest into your HSA.

JACK will also put money into your HSA through bi-weekly contributions and wellness incentives. You can then spend the money in your HSA account on qualified medical expenses or save for the future – it’s your choice!

The Kaiser Permanente HMO 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

Plan Choices

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.

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MEDICAL COVERAGE, CONTINUED

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)

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. 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. Doctors can diagnose, treat, and write prescriptions for most non-emergency conditions. To learn more or get started with a Virtual Visit, go to uhc.com/virtualvisits.

4. Use the emergency room only in EMERGENCIES.

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.

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MEDICAL PLANS AT A GLANCE

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)

$2,700 (I)$5,400 (F)

$5,400 (I)$10,800 (F)

$1,800 (I)1

$3,600 (F)$3,600 (I)1

$7,200 (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)

$400 (I)$800 (F)

$300 (I)$600 (F) N/A

Maximum 2020 HSA Contribution

$3,550 (I) / $7,100 (F)$1,000 catch-up for

those 55+

$3,550 (I) / $7,100 (F)$1,000 catch-up for

those 55+

$3,550 (I) / $7,100 (F)$1,000 catch-up for

those 55+N/A

Bi-Weekly Employee Premium

Coverage LevelsEmployee-OnlyEmployee + Spouse / DP2

Employee + Child(ren)Employee + Family

$50$115$96

$158

$63$145$121$199

$99$228$190$313

$100$230$191$319

Rx Retail & Mail Order3

GenericPreferred BrandNon-Preferred Brand & Specialty

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

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

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 (any coverage level other than Employee-Only)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

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PHARMACY (Rx) BENEFITS

JACK’s UHC pharmacy benefit, administered through OptumRX, includes special coverage for preventive medications. Taking preventive medications as directed by your health care provider can help you avoid serious illness and high health care costs. More information on pharmacy benefits or to look up drug info, coverage and pricing is available at www.myuhc.com. Prescriptions can be filled online, by mail, or by phone.

Below is a summary of prescription drug coverage. More information is available at www.kp.org/formulary. Prescriptions can be filled online, by mail, or by phone.

When you enroll in a UHC or Kaiser medical plan, you are automatically covered under the prescription drug program.

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.

UHC Plans

Kaiser Plan (Southern California)

WHAT YOU WILL PAY

Type of Drugs Network Provider(You pay the least)

Out-of-Network Provider(You pay the most)

Limitations, Exceptions & Other Information

Generic Retail: 20% CoinsuranceMail Order: 20% Coinsurance Retail: 20% Coinsurance 31 day retail / 90 day mail order

Preferred Brand Retail: 40% CoinsuranceMail Order: 40% Coinsurance Retail: 40% Coinsurance 31 day retail / 90 day mail order

Non-Preferred Brand/Specialty

Retail: 50% CoinsuranceMail Order: 50% Coinsurance Retail: 50% Coinsurance

Non-Preferred Only:31 day retail / 90 day mail order

Specialty:Partnered with a Patient Care Coordinator to assist with medication schedule/delivery

WHAT YOU WILL PAY

Type of Drugs Network Provider(You pay the least)

Out-of-Network Provider(You pay the most)

Limitations, Exceptions & Other Information

Generic Retail: $10/prescriptionMail Order: $20/prescription Not Covered

Up to a 30-day supply retail or 100-day supply mail order. Subject to formulary guidelines. No charge for contraceptives.

Preferred Brand Retail: $30/prescriptionMail Order: $60/prescription Not Covered

Up to a 30-day supply retail or 100-day supply mail order. Subject to formulary guidelines. No charge for contraceptives.

Non-Preferred Brand Same as Preferred Brand Not Covered Same as Preferred Brand drugs when

approved through exception process.

Specialty $30/prescription Not Covered Up to 30-day supply retail. Subject to formulary guidelines.

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A unique part of the UHC plans is that it includes a Health Savings Account, or “HSA.” An HSA is a tax-advantaged medical savings account that can be used to pay for qualified medical, dental, vision, and pharmacy expenses, or you can save the money and let it grow tax-free! When JACK puts money into your HSA, it is not subject to federal income tax, however, in California it is subject to state tax. Here’s how it works:1. JACK contributes to your HSA – If you enroll in a UHC plan, there are two ways that JACK will put money into your HSA (consider it

free health care dollars): (1) each bi-weekly pay period, and (2) through participation in our wellness programs. 2. You can contribute to your HSA - If you are enrolled in a UHC plan, you can also put pre-tax money into your HSA each bi-weekly

pay period through payroll deductions. 3. To receive contributions into your HSA by JACK, or to make your own contributions, you must first activate your account by enrolling

and electronically signing the HSA bank agreement (through OptumBank, the HSA administrator). You can access your account through OptumBank directly at www.optumbank or through www.myuhc.com.

4. The IRS sets limits on the annual amount that can be put in your HSA each calendar year (which includes the contributions you receive from JACK each pay period and for participation in any wellness incentives).

5. If your account balance reaches at least $2,000, you may choose available investment funds for your balance.6. Unlike a Flexible Spending Account (FSA), you won’t lose your HSA balance if you don’t spend it each year.

Unspent money can roll over year to year. And, if you leave JACK, your HSA account remains yours.

For more information and resources on HSAs, go to the Total Rewards site in MyUltiStuff. Note: If you are age 65+ and enrolled in Medicare, you (and JACK) are unable to make contributions into your HSA.

2019 2020$3,500 (Individual)$7,000 (Family)

$3,550 (Individual)$7,100 (Family)

Note: Individuals 55 and older, can make an additional $1,000 catch-up contribution each year.

The table below shows the amounts that JACK will contribute directly into your HSA. To receive contributions from JACK or make your own contributions into your HSA, you will need to have an active HSA account with OptumBank.

(1) I = Individual / F = Family (any coverage level other than employee only)(2) You and your spouse can each receive wellness incentives; these incentives are available for both UHC and Kaiser plans. I = Employee; F = Employee + Spouse/Domestic Partner(3) Employee or Eligible Pregnant Spouse/Domestic Partner are eligible

You pay less taxes by lowering your taxable income with before-tax contributions into your account (taxable in CA).

You aren’t taxed on withdrawals you make to pay for eligible health care expenses.

Your account’s earnings and interest aren’t taxed.

Your 3 HSA tax breaks

Item UHC Bronze Plan UHC Silver UHC Gold

Annual JACK Contribution: (1) $500 (I) / $1,000 (F) $400 (I) / $800 (F) $300 (I) / $600 (F)

Annual Wellness Incentives (2) $160 (I) / $320 (F) $160 (I) / $320 (F) $160 (I) / $320 (F)

Total Maximum HSA Contributions $660 (I) / $1,320 (F) $560 (I) / $1,120 (F) $460 (I) / $920 (F)Additional Incentives Available by Participating in the Wellness Programs:

Real Appeal (2)

(if enrolled in UHC Plan and complete 9-week coaching program)

$100 (I) / $200 (F) $100 (I) / $200 (F) $100 (I) / $200 (F)

Maternity Support (3)

(if enrolled in UHC Plan; Kaiser participants, contact benefits@jackinthebox.com)

$150 $150 $150

HEALTH SAVINGS ACCOUNT (HSA)

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This is an online weight loss/lifestyle program intended to help you lose and manage your weight, prevent chronic disease, live healthier, and ultimately save you money on medical expenses. If you qualify to participate in the program and complete the 9 weekly coaching sessions, you can receive a reward of $100.

Key Points:• Available to all employees and spouses enrolled in our UHC medical plans only. • If you qualify for the program, based on weight/BMI, you will receive a success kit, weekly online group sessions, and more. Some

may also qualify for one-on-one personalized consultations.• To learn more, visit www.realappeal.com.

WELLNESS PROGRAMSJACK wants to help you get healthy and stay healthy! That’s why we offer financial incentives for you to engage in healthy activities throughout the year – don’t leave $$$ on the table! There are three ways you can earn rewards if you are enrolled in our medical plans.

RallyA simplified Rally program rewards you for activities that keep you moving*. More specifically, every 3 months there will be a JACK private team challenge. If you participate in the challenge and meet the minimum miles requirement, JACK will contribute monies into your HSA account (for UHC participants) or will provide a credit to your bi-weekly medical premiums (for Kaiser participants or participants enrolled in Medicare). An added benefit is that JACK will make a $1,000 contribution to the winning team’s charity!

Key Points:• To participate, you must activate your Rally account (one-time). Once you have

a Rally account, at the beginning or anytime during the benefit plan year, you have the opportunity to complete the Rally Health Survey. You will be able to participate in the team challenges throughout the year – you will be notified by Rally each time you can enroll in a private team challenge.

• A tracking device (such as a Fitbit, Garmin, or compatible Android phone or iPhone) is required to track your activity during the private team challenges.

• Both employee and spouse/DP enrolled in our medical plans are eligible to earn their own reward.

• You can continue to participate in the missions and other activities on the RALLY site to earn coins.

*If you need an alternative accommodation due to physical limitations, contact benefits@jackinthebox.com.

Four Private Challenges

Total Rewards

$40each

=$160

Maternity SupportTo ensure the health of mother and baby, maternity support is offered to provide resources and tools for before, during and after pregnancy. Upon completion of the UHC or Kaiser maternity support programs, JACK provides a reward of $150.

Key Points:• Pregnant employees and spouses/DP on our medical plans are eligible for the reward.• For UHC plan participants, JACK will contribute $150 into your HSA account.• For Kaiser participants, a Maternity Attestation document must be signed and returned to benefits@jackinthebox.com to receive the

reward. The $150 will then be applied as a credit to your bi-weekly medical premium.

DENTAL COVERAGERegular dental care is just as important as regular medical care and that is why JACK offers you a comprehensive dental plan. Our dental plans through MetLife provide coverage for preventive services and pay a portion of more expensive dental procedures such as fillings, root canals, crowns, bridges and orthodontia.

Under the dental plan, you are free to go to any licensed dental provider you choose – but if you go to a dentist who is a member of MetLife’s network, you can reduce your Out-of-Pocket costs. There is no dental ID card necessary.

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 in the MetLife

network that have agreed to provide service to plan members at discounted rates. • Out-of-Network Dentists. If you use a dentist who is not in the MetLife network, the plan will pay only 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.

Preventive and diagnostic services (such as teeth cleanings, oral exams, fluoride, sealants and bitewing x-rays) are not subject to the deductible and are paid at 100%.

Employees enrolled in a JACK medical plan can enroll eligible spouses and dependents in dental coverage, even if the spouse and dependents are not enrolled in a JACK medical plan.

Coverage Type In-Network Out-of-Network1

Type A: PreventiveCleanings, Exams, X-rays 100%, no deductible 100% of R&C, no deductible

Type B: Basic RestorativeFillings, Extractions, TMJ 80%, after deductible 80% of R&C, after deductible

Type C: Major RestorativeBridges, Dentures, TMJ 50%, after deductible 50% of R&C, after deductible

Type D: Orthodontia 50%, after deductible 50% of R&C, after deductible

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

Annual Maximum Benefit $2,500 per person $2,500 per person

Orthodontia Lifetime Maximum $1,500 per person $1,500 per person

Tier Bi-Weekly Employee Premium

Employee-Only $7

Employee+Spouse/Domestic Partner $15

Employee+Children $12

Employee+Family $20

Find a DentistTo find a network dentist, visit www.metlife.com/mybenefits or call (800) 942-0854.

Admin 13

1R&C: Reasonable & Customary Charge

VISION COVERAGEThe VSP Choice 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.

To find a VSP provider, visit their website at www.vsp.com or call (800) 877-7195. Once you enroll, make an appointment with your provider and let the provider know that you have VSP Choice insurance coverage. They will verify your coverage and eligibility before you arrive for your appointment. There is no vision ID card necessary.

Employees enrolled in a JACK medical plan can enroll eligible spouses and dependents in vision coverage, even if the spouse and dependents are not enrolled in a JACK medical plan.

Benefit In-Network Frequency

Well Vision Exam $25 copay Every 12 months

Prescription Glasses $30 copay for lenses and/or frames; $160 allowance

Frames: Every 24 monthsLenses: Every 12 months

Contacts (Instead of glasses) $160 allowance Every 12 months

Lens Enhancements $0-$175 depending on service Every 12 months

Diabetic Eyecare Plus $20 copay As needed

Tier Bi-Weekly Employee Premium

Employee-Only $2.13

Employee+Spouse/Domestic Partner $2.84

Employee+Children $3.35

Employee+Family $5.35

Find a Vision ProviderTo find a VSP provider, visit their website at www.vsp.com or call (800) 877-7195.

Admin 14

Admin 15

FLEXIBLE SPENDING ACCOUNTS (FSA)An FSA offers you a way to save money on your health care and/or dependent care expenses using pre-tax dollars. Your annual election is deducted from your bi-weekly paycheck in equal amounts. You can either use your Health Care Spending card or reimburse yourself when you submit documentation online for qualified health care services. The IRS has a “Use It or Lose It” rule

that requires you to use the full amount you contribute to your FSAs for eligible expenses incurred during the plan year (October 1, 2019 – September 30, 2020) (except for a carryover of up to $500 for the health care FSA), so be sure to estimate your FSA amount wisely. See which accounts are available to you and how you can use them in the chart below.

(1) Limited purpose FSA applies to all UHC plans

Healthcare FSAs

Dependent Care FSALimited Purpose FSA(HSA Compatible)1 Traditional FSA

Eligible Expenses Dental and Vision Expenses Only Medical, Dental and Vision Child Care and Elder Care

Available To Employees enrolled in the UHC Plans (Gold, Silver and Bronze)

Benefit Eligible Employees enrolled in the Kaiser Plan or who waived

medical coverageAll Benefit Eligible Employees

Annual Contribution Amounts Up to $2,500 Up to $2,500 Up to $5,000 (Up to $2,500 if

married and filing separately)

Money is Available to Use

Funds are available on Health Care Spending card, effective your first

day of coverage.

Funds are available on Health Care Spending card, effective your first

day of coverage.

Your account is funded bi-weekly with the deductions from your pay-check and available after 3 business

days (not including holidays). You must pay for your dependent care

expenses before you can file a claim online for reimbursement.

Account Dollars Carry Over Year to Year

Can carry over up to $500 of unused funds to following year – any funds over that amount are forfeited. Carryover funds are

available in mid-January following the end of the plan year.

Can carry over up to $500 of un-used funds to following year – any funds over that amount are forfeit-ed. Carryover funds are available in mid-January following the end of

the plan year.

Contributions amounts are not car-ried over from one year to the next. Any unused amounts are forfeited.

Last Day to Spend Plan Year 2019/2020 FSA Dollars

SEPTEMBER 30, 2020

December 31, 2020 is the last day to submit PY2019/2020

FSA claims.

SEPTEMBER 30, 2020

December 31, 2020 is the last day to submit PY2019/2020

FSA claims.

SEPTEMBER 30, 2020

December 31, 2020 is the last day to submit PY2019/2020

FSA claims.

Admin 16

PROTECTING YOUR INCOMEJACK wants to make sure you and your family are protected in the event of your death or a serious injury. We offer a variety of Life and Disability insurance plans for you to choose from – 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

• Employer-paid Term Life Insurance equal to one times your annual salary, up to a maximum of $250,000.• Pays benefits to your beneficiary upon your death, benefit is reduced if death occurs on or after age 65.• 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 – the amount you pay each bi-weekly pay period for this benefit is based on an age-based rate structure.

• You can purchase coverage in increments of $10,000 up to a maximum of three times your annual salary or $750,000, whichever is less (amounts above $450,000 requires an EOI).

• 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.

• You can enroll or change coverage at any time, however an increase over $10,000 in coverage requires an EOI If you enroll within your initial date of hire eligibility period (within 30 days of your effective date), no EOI is required.

Accidental Death and Dismemberment (AD&D)

• You pay the full cost for this coverage – the amount you pay each bi-weekly pay period is based on the level and amount of coverage you purchase.

• Can be purchased for yourself and your eligible dependents.• For yourself, you can purchase coverage in increments of $10,000 up to a maximum of $500,000 (not to exceed

ten times earnings for amounts over $250,000).• for your spouse (with no children), you can purchase coverage equal to 50% of your coverage amount• for your spouse (with children), you can purchase coverage equal to 40% of your coverage amount• for your children (with spouse), you can purchase coverage equal to 15% of your coverage amount for

each child• for your children (without spouse), you can purchase coverage equal to 20% of your coverage amount for

each child

Short-Term Disability(STD)

• You pay the full cost for this coverage – Not available in CA, HI, NJ, NY, RI (these states provide state disability insurance).

• Provides coverage for disability (six months or less) resulting from a covered injury or sickness if you are totally disabled and can’t work.

• Weekly benefit is amount equal to 55% of covered earnings, up to maximum benefit of $602 per week.• Benefits begin on the 8th consecutive day of disability.• Maximum benefit of 25 weeks for one period of disability.• Important Note: If you enroll more than 30 days after your effective date, and you become disabled within the

first year of coverage, your benefit won’t begin until the 61st day of being totally disabled.

Long-Term Disability(LTD)

• You pay the full cost for this coverage • Provides coverage for disability (more than six months) resulting from a covered injury or sickness if you are

totally disabled and can’t work.• Benefit equals 60% of your monthly covered earnings (if you are not eligible for other disability benefits such as

Social Security disability insurance), up to a maximum benefit of $5,000 per month.• Benefits begin after you’ve been totally disabled for six consecutive months.• Maximum benefit period is based on your age when you become totally disabled, but no later than your Social

Security Normal Retirement Age.• LTD benefits are different for “highly compensated employees.” Refer to plan description on Total Rewards site

in MyUltiStuff.• You can enroll or change coverage at any time, however an increase in coverage requires an EOI. If you enroll

within your initial date of hire eligibility period (30 days of your effective date), no EOI is required.

Admin 17

METLAW LEGAL PLANSJACK is pleased to offer a new benefit beginning plan year 2019/2020, MetLaw, provided by Hyatt Legal Plans. MetLaw provides telephone advice and office consultations for an unlimited number of personal legal matters and full representation for the services in the table below. This is a voluntary benefit and you can choose from a High or Low Plan. The plan covers you, your spouse and dependents.

Eligible employees can enroll in the MetLaw Legal Plans only during Annual Benefits Open Enrollment. New employees hired after Annual Benefits Open Enrollment are eligible to enroll within 30 days following one month of service.

Important: If you choose to enroll in the plan, you must remain in the plan for the full benefit plan year. New employees enrolling in the legal plan outside of our Annual Open Enrollment must remain in the plan for the remainder of the benefit plan year in which they enroll. 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.

High Plan$8.54/pay period

Web Access Code: 9902523

Web Access Code: 9902525

Low Plan$3.81/pay period

Services AvailableIf you enroll in either the High or Low plan, you and your eligible dependents are entitled to receive legal services at no cost or at discounted rates. 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• Wills, Power of Attorney• Consumer Protection• Consultation & Documentation Review for issues related to your parents

• 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, including a complete list of covered services as well as exclusions, go to www.myultistuff.com, Total Rewards site under Documents & Contacts tab.

Admin 18

MORE PROGRAMS AVAILABLE TO YOUEmployee Assistance Program (EAP)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 Absence (LOA)JACK 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

Employer Paid Business Travel AccidentJACK provides employer-paid Business Travel Accident (BTA) insurance coverage in the event of illness or injury while traveling on JACK business.

The maximum benefit is three times your annual salary or $50,000, whichever is greater. How much you receive is a percentage of the maximum benefit amount, depending on the extent of your injuries. Coverage is provided through A.C. Newman & Company.

Admin 19

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.

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 – $19,000 for 2019). If you are age 50 or older, or will turn 50 during the calendar year, you are eligible to make an additional $6,000 “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.”

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.

Here’s how you enroll……Easy 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.

Admin 20

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

1-800-500-5255, 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

MetLife 1-800-942-0854www.metlife.com/mybenefits 304081

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

VSP 1-800-877-7195www.vsp.com 00103013

Health Savings Account (HSA) Optum Bank1-866-234-8913 Option 1www.optumbank.com

www.myuhc.com

Policy Number:704025

Health Care and Dependent Care FSA UHC 1-877-468-0979www.myuhc.com

Policy Number:908484

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

Reliance Standard 1-800-351-7500www.RelianceStandard.com N/A

Short-Term and Long-Term Disability Reliance Standard 1-800-351-7500www.RelianceStandard.com N/A

MetLaw Legal Services• Welfare Benefit Plan for Group Legal

ServicesMetLaw 1-800-821-6400

www.legalplans.com9902525 - Low Plan9902523 - High Plan

Business Travel Accident A.C. Newman & Company 1-559-252-2525www.acnewman.com N/A

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: JIBEAPN/A

Wellness Programs• Information on the Rally Engage UHC www.myuhc.com

Kaiser members visit www.werally.com N/A

Real Appeal Weight Loss Program• Information on the Rally Engage Real Appeal www.realappeal.com N/A

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

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

Leave of Absence (LOA) Matrix Absence Management

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

Policy Number:704025

COMPLIANCE NOTICES The following notices are provided for your information and as required by federal law. In the event that additional disclosures are required after that time, the additional disclosure will be provided to you separately. This summary does not address specific state laws, which may be more expansive than federal law, and therefore you may have certain additional rights under your state law that are not addressed here. If you have any questions about any of these notices or information, please contact:

Jack in the Box Inc. Benefits Department

benefits@jackinthebox.com For details on the benefit and claims review and adjudication procedures for each plan, please refer to the plan’s Evidence of Coverage. If there are any discrepancies between benefits included in this summary and the Evidence of Coverage or Summary Plan Description/Plan Document, the Evidence of Coverage or Summary Plan Description/Plan Document will prevail.

Summaries of Benefits and Coverage (SBCs) 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. SBCs for your medical plan choices can be found at www.myultistuff.com, Total Rewards, Documents & Contacts tab. Women’s Health & Cancer Rights Act In accordance with the Women’s Health and Cancer Rights Act (WHCRA) of 1998 (WHCRA), if you have had or are going to have a mastectomy, you are entitled to certain benefits and your coverage will be provided in a manner determined in consultation with the attending physician and patient for:

• All stages of 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 the mastectomy, including lymphedema.

Newborns’ and Mothers’ Health Protection 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 hours 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 or 48 hours (or 96 hours).

Health Insurance Portability & Accountability Act (HIPAA) Special Enrollment Rights If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may be eligible to enroll yourself or your dependent’s in this Plan in the future, provided that you request enrollment within 30 days after your other coverage ends (60 days if the lost coverage was Medicaid or Healthy Families). 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. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. In addition, you may be able to enroll yourself and your dependents in coverage: (1) if your or your dependent’s coverage under a Medicaid plan or a State Children’s Health Insurance Program (“CHIP”) plan terminates due to loss of eligibility for such coverage; or (2) you or your dependents become eligible for premium assistance under Medicaid or CHIP. However, you must request enrollment within 60 days after the date of termination of such coverage or the date you or your dependent is determined to be eligible for such assistance, whichever is applicable. 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 Privacy Notice In accordance with the Privacy Rule under HIPAA, this Privacy Notice describes how protected medical information about you may be used and disclosed and how you can obtain access to this information. This is a reminder about the availability of the Notice and that you can find a copy of the Jack in the Box Inc. Notice of Privacy Practices in www.myultistuff.com, Total Rewards, Documents & Contacts tab. Please review it carefully.

Medicare Part D Notice For Employees Enrolled in United HealthCare and Kaiser Plans Important Notice from Jack in the Box about Your Prescription Drug Coverage and 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:

• 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.

• Jack in the Box Inc. has determined that the prescription drug coverage offered by the United HealthCare and Kaiser Plans 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. 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 Jack in the Box Benefits Department at benefits@jackinthebox.com 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 changes. You also may request a copy of this notice at any time. 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). 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 of Issue: August 5, 2019 Name of Entity/Sender: Jack in the Box Inc. Contact-Position/Office: Benefits Department Address: 9330 Balboa Ave, San Diego, CA 92123 Phone Number: (800) 500-5225

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 July 31, 2018. Contact your State for more information on eligibility –

ALABAMA – Medicaid FLORIDA – Medicaid

Website: http://myalhipp.com/ Phone: 1-855-692-5447

Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268

ALASKA – Medicaid GEORGIA – 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://dch.georgia.gov/medicaid - Click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507

ARKANSAS – Medicaid INDIANA – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

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

COLORADO – Health First Colorado (Colorado’s Medicaid Program) &

Child Health Plan Plus (CHP+) IOWA – Medicaid

Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: Colorado.gov/HCPF/Child-Health-Plan-Plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711

Website: http://dhs.iowa.gov/hawk-i Phone: 1-800-257-8563

KANSAS – Medicaid NEW HAMPSHIRE – Medicaid

Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512

Website: https://www.dhhs.nh.gov/ombp/nhhpp/ Phone: 603-271-5218 Hotline: NH Medicaid Service Center at 1-888-901-4999

KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP Website: https://chfs.ky.gov Phone: 1-800-635-2570

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

LOUISIANA – Medicaid NEW YORK – Medicaid Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447

Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831

MAINE – Medicaid NORTH CAROLINA – Medicaid Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711

Website: https://dma.ncdhhs.gov/ Phone: 919-855-4100

MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-862-4840

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIP Website: https://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/other-insurance.jsp Phone: 1-800-657-3739

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

MISSOURI – Medicaid OREGON – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

MONTANA – Medicaid PENNSYLVANIA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

Website: http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htm Phone: 1-800-692-7462

NEBRASKA – Medicaid RHODE ISLAND – Medicaid Website: http://www.ACCESSNebraska.ne.gov Phone: (855) 632-7633 Lincoln: (402) 473-7000 Omaha: (402) 595-1178

Website: http://www.eohhs.ri.gov/ Phone: 855-697-4347

NEVADA – Medicaid SOUTH CAROLINA – Medicaid

Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900

Website: https://www.scdhhs.gov Phone: 1-888-549-0820

SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059

Website: http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-program Phone: 1-800-562-3022 ext. 15473

To see if any other states have added a premium assistance program since July 31, 2018, 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 display 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 respondent. 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 Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.

OMB Control Number 1210-0137 (expires 12/31/2019)

TEXAS – Medicaid WEST VIRGINIA – Medicaid Website: http://gethipptexas.com/ Phone: 1-800-440-0493

Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669

Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-362-3002

VERMONT– Medicaid WYOMING – Medicaid Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531

VIRGINIA – Medicaid and CHIP Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282