Welcome to your Premera HSA plan

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1 Welcome to your Premera HSA plan Company name Effective

2 SAVINGS Get started You re enrolled in the HSA plan from Premera Blue Cross. It comes fully assembled and integrated, so you can immediately enjoy the financial advantages of its health savings account, coverage from its health plan, and online access so you can easily manage both. What s an HSA? The HSA is a health savings account where you can save money before income taxes are taken out and use to pay for your current or future IRS-approved medical expenses. Your HSA is opened automatically $ Your HSA has been opened for you at a federally insured bank by ConnectYourCare (CYC), an independent company that administers health savings accounts on behalf of Premera Blue Cross. Your HSA belongs to you It does not belong to your employer, even if your employer contributes money to it. Nor does it belong to Premera Blue Cross. The HSA and the money you ve saved in it are yours, even if you decide to change jobs, switch health plans, or retire. No bank fees $ Unlike many other banks, Premera HSA plan participating banks will not charge you any transaction, account, or administrative fees for opening, maintaining, or using your HSA. You ll soon receive information about your HSA from the bank acting as the custodian of your HSA funds. THERE IS NO USE IT OR LOSE IT RULE You can let the money in your HSA roll over from year to year. So there s no need to rush out and spend your money at the end of the plan year.

3 Pre-tax contributions to your HSA Just like a 401(k) or individual retirement account (IRA), you can have money deducted from your paychecks by your employer before income taxes are taken out and deposited into your HSA. For calendar year 2016, you may deposit up to these IRS limits: 2016 CONTRIBUTION LIMITS INDIVIDUAL $3,350 FAMILY $6, catch up payment $1,000 You can change the amount you contribute to your HSA or make a lump-sum deposit to your account whenever you want. Does your employer contribute to your HSA? If yes, this money will count towards your contribution limit. So make sure to account for this amount when calculating how much you want to contribute to your HSA on a yearly basis so you don t exceed IRS limits. To pay or not to pay healthcare bills with your HSA You decide when and how to pay with your HSA. Once your savings reach $1,000, you ll be able to invest your money in over 100 no-load, no-transaction-fee mutual funds. YOU pay using your healthcare payment card It s like a debit card, immediately accessing the money in your HSA to pay on the spot. You ll receive your card soon, if you haven t already. OR $ $ $ YOU pay out-of-pocket Leave your HSA funds untouched $ to let your savings grow for future expenses. When a provider does not submit a claim to Premera Here s what you should do: 1 Pay out-of-pocket for the service or product. 2 Submit a medical claim to Premera for the total cost. 3 Check the Explanation of Benefits (EOB) statement you ll receive to see how much of the cost is covered by your plan. If the amount covered is less than what you paid out-of-pocket, you can request a reimbursement from your HSA for the remaining amount.

4 Use your HSA for IRS-approved expenses Also called qualified medical expenses, there are many of these expenses you can pay for with your HSA: Medical care and services, including office visits, hospitalizations, and lab tests Deductible, copays, coinsurance Prescription drugs Dental care Vision care and eyewear Learn more when you log in at premera.com to manage your account. Pay your family s healthcare expenses, too Use your HSA funds to pay any approved expenses of your spouse and dependents (generally someone you can claim as an exemption on your tax return). You can pay their healthcare expenses even if they are not covered by your health plan. Paid for expenses not approved by the IRS with HSA? Whoops. If you spend your HSA money on anything other than IRS qualified medical expenses, then you may have to: 1 Report the amount of unqualified expenses on your tax return 2 Pay income tax on the amount 3 Pay a 20 percent penalty (you will not be penalized if you re 65 or older or disabled) Save your itemized receipts, it s important! Non-itemized cash register tapes, credit card receipts, and canceled checks alone are not proper proof of your purchases. Receipts must contain the following information: Name of patient or person receiving service Date of service Name and address of provider Description of the service or product purchased Amount charged Also keep any documents verifying that you used your HSA money for an IRS-approved expense. Plus they re great reminders when you need to reimburse yourself.

5 COVERAGE How your health plan works You re covered by a Premera health plan, too! You ll soon receive a welcome guide explaining how to take advantage of your Premera plan s benefits. In the meantime, here s a brief overview of the plan and how it works with your HSA. Plan Year WE pay 100 % PREVENTIVE exams, screenings, specific generic Rx COVERED IN FULL WE pay covered services YOU pay non-preventive care and prescriptions until you reach deductible YOU pay 100 % $ 0 we BOTH pay coinsurance for covered services out-of-pocket maximum met deductible met For details about your plan s actual preventive benefits see your preventive benefits list, summary of benefits, and your benefit booklet on premera.com.

6 Things to know about using your plan s benefits Use in-network providers Your health plan has a specific group of doctors, pharmacies, hospitals, and other healthcare providers in its network. You will pay less if you use these in-network providers. (The name of your provider network can be found on your Premera ID card.) Certain generic preventive drugs are covered in full These drugs include certain generic cardiovascular and oral diabetic medications. (You soon will receive a Premera welcome kit that includes a list of these drugs. For a general list, go to premera.com/hsa.) Save money by buying generic Ask your doctor if lower-cost generic drugs are right for you. Most preventive care and tests are covered at 100 percent You don t pay anything for these services, which are important in maintaining long-term good health. Preventive care includes regular checkups, immunizations such as flu and tetanus shots, and screenings such as blood pressure and cholesterol tests. Log in at premera. com to see which preventive services are covered in full. PREVENTIVE VERSUS DIAGNOSTIC TESTS Tests are preventive before a medical condition is detected. Preventive tests are covered at 100 percent. Tests are diagnostic after a condition has been diagnosed. You may be responsible for paying part of the cost of diagnostic tests.

7 CONVENIENCE Manage your HSA at premera.com At work, at home, or on the go you have instant, convenient access to your HSA. Log in at premera.com and click Personal Funding Accounts under Manage My Account to: See qualified medical expenses Go to Help & Tools to see the IRSapproved expenses that you can pay for with your HSA. Check your account balance Go to Accounts & Balances. Track and manage your claims Under Payments & Reimbursements you can set up recurring claims and view existing claims from your health plan, HSA, and healthcare payment card transactions. Manage HSA contributions Go to Accounts & Balances to adjust the amount you deposit or make a lump-sum deposit. Invest your HSA savings Go to Accounts & Balances to access mutual funds through a fully integrated investment center. Request healthcare payment cards Go to My Payment Card to add a cardholder, replace a damaged card, or report a lost or stolen card. Manage your account on your phone Download CYC Mobile to: View account balance, claims, transaction history and alerts Instantly upload your receipts Submit a claim to get reimbursed from your HSA

8 Call for more information about your HSA. Premera Blue Cross is not an administrator, trustee or fiduciary of any health savings account which may be used by a plan member in conjunction with a health plan. This material is not intended to be tax or legal advice. The reader should consult with his or her own tax advisor to determine the tax implications of purchasing the products discussed herein. Advice, if any, included in this material was not intended or written by Premera to be used, and it cannot be used, by any taxpayer for the purpose of avoiding penalties that may be imposed on the taxpayer. ConnectYourCare (CYC) is an independent company that provides health savings account services on behalf of Premera Blue Cross ( )