Welcome to your Premera HSA planCompany nameEffective 1.1.2016

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.

You’ll soon receive information about your HSA from the bank acting as the custodian of your HSA funds.

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.

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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.

SAVINGS

Get started

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.

Once your savings reach $1,000, you’ll be able to invest your money in over 100 no-load, no-transaction-fee mutual funds.

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.

OR

using your healthcare payment card

YOU pay

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.

To pay or not to pay healthcare bills with your HSAYou decide when and how to pay with your HSA.

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.

2016 CONTRIBUTION LIMITS

INDIVIDUAL $3,350

FAMILY $6,750

55+ 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.

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:

out-of-pocket YOU pay

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Leave your HSA funds untouched

to let your savings grow for future expenses.

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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)

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.

Use your HSA for IRS-approved expenses

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.

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.

COVERAGE

How your health plan works

For details about your plan’s actual preventive benefits see your preventive benefits list, summary of benefits, and your benefit booklet on premera.com.

PREVENTIVEexams, screenings, specific generic Rx

COVERED IN FULLdeductible met

out-of-pocket maximum met

Pla

n Ye

ar

YOU paynon-preventive care and prescriptions until you reach deductible

WE pay

WE pay

covered services

YOU pay

we BOTH paycoinsurance for covered services

100%

100% $0

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.

Things to know about using your plan’s benefits

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.

At work, at home, or on the go— you have instant, convenient access to your HSA.

CONVENIENCE

Manage your HSA at premera.com

See qualified medical expenses

Go to Help & Tools to see the IRS-approved 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

Log in at premera.com and click Personal Funding Accounts under Manage My Account to:

020381 (01-2016)

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.

Call 800-941-6121 for more information about your HSA.