empireblue.com

Congratulations on enrolling in Empire Total Blue with HSA* (Health Savings Account) — a health plan that empowers you to make decisions that affect how, when and where you spend your health care dollars.

Empire Total Blue with HSA combines a high-deductible PPO health plan along with a tax-free HSA to help pay for qualified medical expenses. You also have access to the tools and resources you need to make smart health care decisions, keep your expenses to a minimum, and in many cases, save money.

And of course, we support you with the superior service, reliability and peace of mind that comes with the Empire BlueCross BlueShield (Empire) brand.

<Your employer> has arranged for BNY Mellon to set up an HSA in your name.

You may have already received your Empire Total Blue ID card. An HSA Bank Kit from BNY Mellon will be arriving shortly. In it, you’ll find a signature card that you must complete and return before your HSA can be activated. Alternatively, you may also activate your account online on the date your health plan becomes effective. To activate online, go to empireblue.com and register for Member Online Services. After returning your signature card or activating your account online, contributions to your account can be deposited. You can access your funds with a debit card or checkbook. The debit cardwill be sent to you automatically by BNY Mellon, as well as a checkbook, if you select that option.

In the meantime, take a few moments to review the materials we’ve included in this Empire Total Blue Welcome Kit:

Getting the Most Out of Your Health Plan. This informative brochure provides you with everything you need to know about your high-deductible health plan, including how it works at the doctor’s office — how to manage your HSA funds — and how to access the tools available to help you make smart health care decisions.

Letter to your provider. Empire has made great progress in educating our network providers on how your plan works. In the event your provider is not familiar with your plan, please show this letter to your provider. It provides an overview of your plan’s key features, including payment details. Providers who have additional questions can contact the number listed in the letter.

Lastly, we hope you’ll take a few minutes to answer some questions that will allow Empire to better coordinate your benefits. Thepurpose of our coordination of benefits (COB) effort is to provide maximum coverage and minimize your administrative hassles whenyou need care. In order to achieve this, we need to know whether any member of your family has any medical coverage in addition toyour Empire health plan. You can call us directly at <phone number> or visit our website, empireblue.com, and complete our COB questionnaire online.

If you have questions about your HSA or Empire Total Blue plan benefits, contact Empire at <phone number>, Monday through Friday, 8:30 a.m. to 8 p.m. EST.

Again, welcome to Empire Total Blue with HSA. We know you’ll be delighted with your new health care coverage.

Sincerely,

Empire BlueCross BlueShield

* HSAs are provided through the custodian bank. HSAs are not an insurance product and are not a part of the Empire Total Blue Health Plan.Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Welcome to Empire Total BlueSM with HSA!

empireblue.com

Dear Provider:

The patient presenting you with this letter has enrolled in Empire Total Blue, a consumer-directed health plan administered by Empire BlueCross BlueShield (Empire). Empire Total Blue is a high-deductible PPO health plan that features:

In-network preventive care services covered, with no deductible.

A tax-free Health Savings Account (HSA) that is used to pay for qualified medical expenses.

No copayments. Please do not collect any money from this patient at point of service. The plan has a deductible that must be met before coinsurance applies and benefits are paid.

No referrals needed to see specialists, reducing the “hassle factor” for members and providers.

As you no doubt know, consumer-directed health care has been in the news, and you can expect more and more of your patients to enroll in programs such as Empire Total Blue. For this reason, we thought you’d appreciate knowing how the process for billing and payment works. Take a moment to review the diagram below to see how Empire Total Blue helps simplify the collection of fees for you:

See other side for an important note about billing members with the Empire Total Blue plan …

*Blue Cross Blue Shield means, depending on the context, either Empire BlueCross BlueShield or your local Blue Cross and/or Blue Shield plan, independent licensees of the Blue Cross and Blue Shield Association.

Empire Total BlueSM member:Please give this letter to your health care provider.

For illustrative purposes only. Diagram does not reflect actual rates.Diagram illustrates in-network benefits.

Member seeks careat doctor’s officeand pays nothing

at the office.

Doctor submitsclaim for office visit

for $100.

BCBS* processes the claim at a discounted

rate = $60.BCBS applies the $60toward the member’s in-network deductible.

BCBS sends Explanation of Benefits (EOB) to doctor.

BCBS sends EOB to member indicating member responsibility.

Doctor bills member for $60.**

**member chooses to pay $60 from HSA by check or debit card or from other personal funds to save HSA dollars.

NOTE: when providing services to your Empire member patients …please remember that since there are no copayments with this plan, you should wait for an EOB from Empire before collecting payments from patients. This EOB will indicate the member’s financial responsibility that you will use for billing.

Thank you for providing services to our Empire Total Blue members.If you have any questions about payments or benefits, please don’t hesitate to call Empire at the phone number on the back of the member’s ID card. Select the provider prompt (#), enter the required member ID and date of birth information, and when the next prompts are given, press “0” and you will be connected to an Empire representative.

Sincerely yours,

Empire BlueCross BlueShield

Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Getting the most from your Empire Total BlueSM with Health Savings Account

C O N S U M E R - D R I V E N H E A L T H C A R E

What’s Inside:Getting started 1 Using health care services 2 Let your HSA work for you 3 Understanding your EOB 4 How does your consumer-driven health plan work 5 Filling a prescription 6 Going to a hospital 7 360° Health tools and services 8 FAQs 9 Unmatched service excellence 10

Getting started in a new health plan can be confusing.That’s why we’ve created this comprehensive guide to walkyou through the components of your new health plan.

Getting started

Consumer-driven health plans are designed to inform you about health care options and empower you to take control of your health, as well as the dollars you spend on your care.

Health care dollars to spend your way – and save for the future

A unique aspect of this health plan is that you’ll have the opportunity to open a bank account for your health care expenses.

Here’s how the plan works:

Health account – You can either use the funds available in your Health Savings Account (HSA) or you can pay out of pocket for covered medical care and prescriptions. Unlike traditional health plans, prescriptions do apply to deductible requirements.

Preventive care – Plus, get 100% coverage for covered preventive care services, with no deduction from your health savings account or out-of-pocket costs for you if you receive covered services from an in-network provider.

Traditional health coverage – Traditional health coverage helps protect you from additional care expenses. When using funds from your health savings account or from your own pocket, you are accountable for paying a set amount for health care and prescriptions before the traditional health coverage begins.

And here’s another feature: Unused dollars from your health account are saved from year to year. That means if you have dollars left in your account at the end of the year, you could start out next year with even more dollars at your disposal. In addition, even if you elect to discontinue coverage under your HSA plan or discontinue working for your employer, you can take your account with you.

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Using your Empire Total Blue plan What is an HSA?

Your Health Savings Account

Your employer has given you the opportunity to open an HSA provided through a financial institution on your behalf. Shortly before your effective date, you will receive an HSA Welcome Kit from your HSA financial institution. This kit contains all of the necessary information you’ll need to activate your HSA and access your account.

Quarterly e-statements – You will receive quarterly e-statements from your financial institution that detail your account transactions, such as deposits, withdrawals and balance, as well as any interest earned.

Making contributions to your HSA

Each year, the Internal Revenue Service (IRS) establishes the criteria for HSA contributions.

To be eligible, you must meet these criteria:

}} You must be covered by an HSA-compatible health plan, such as Empire’s HSA plan, and you cannot be covered by any other medical plan that is not an HSA-compatible health plan. This would include being enrolled in your spouse’s plan as secondary coverage, or an executive medical plan. Note: Federal law requires minimum deductible levels for individual and family coverage for HSA-compatible health plans.

}} You must be enrolled in the plan on the first day of the month (otherwise, your eligibility to make contributions to your HSA begins the first day of the following month). You may make the maximum annual HSA contribution for the year regardless of the month you become eligible.

Note: We do not offer tax advice. You should check with your tax advisor about HSA tax implications.

Using health care services

Receiving care through your health plan is simple. You don’t need to select a primary care physician or get a referral to see a specialist. You have a choice of seeing doctors and specialists participating in the extensive BlueCard® PPO program.

With the Empire Total Blue plan, you and your doctor decide where and when you receive covered services. And, you don’t need referrals before seeing a specialist. If you don’t already have a relationship with a doctor, don’t worry – approximately 80% of doctors across the country participate in the BlueCard® PPO program.1 We can help you find one who meets your needs.

And remember, in most cases, if you choose an in-network provider, you may pay less for your care, and the provider will file your claims for you.

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General – Annual physical examination, diagnostic screening tests (tests for certain diseases when a covered member has no evidence of that disease) and colorectal cancer screenings.

Well-woman care – Visits to a gynecologist/obstetrician for preventive obstetric and gynecological service, and screening for cervical cancer with the Pap smear; bone density testing and treatment; mammography screenings; and screenings for diabetes mellitus in pregnant women at the appropriate stage of pregnancy or for women who are contemplating pregnancy.

Well-child care – Visits to a pediatrician, nurse or licensed nurse practitioner for a physical examination, medical history, developmental assessment and guidance on normal childhood development and laboratory tests, as well as immunizations.

Preventive care is an important and valuable part of your health care Regular physical checkups and appropriate screenings can help you stay healthy. When you detect and treat an illness or condition early, you can help minimize the risk of a serious health problem and reduce the risk of incurring greater costs.

The following preventive services are examples of what may be covered when you use in-network providers:2

Note: Some preventive services are subject to age and frequency limitations.

1 Internal data, November 2011.2 Check your benefits materials or call Member Services at the number on the back of your ID card to confirm coverage.

}} You must not be enrolled in Medicare.

}} You must not be eligible to be claimed as a dependent on another individual’s tax return.

}} You must be a U.S. resident, and not a resident of American Samoa.

}} If you are a veteran, you may not have received veterans’ benefits within the last three months.

}} You must not be active military.

You may contribute money to your HSA up to a maximum contribution limit set by the U.S. Treasury and the IRS. Combined contributions to your account cannot exceed your annual contribution maximum. For 2013, the annual contribution maximum set by the U.S. Treasury and the IRS is $3,250 for individual coverage and $6,450 for family coverage. The contribution maximums set by the U.S. Treasury and the IRS may be increased for inflation annually.

Making contributions to your HSA

Let your HSA work for you

Funds in your HSA earn tax-free interest and accumulate year over year – giving you additional money to pay for future health care expenses. You can also invest your HSA dollars in mutual funds through your HSA financial institution. There’s typically a minimum balance required in your HSA before you can invest in mutual funds. Check with your financial institution for details.

Tax savings

Not only can you build up funds in your HSA to pay for future health care expenses, but you save money on taxes each year. Here’s how your HSA can generate tax savings for you:

4�Contributions to your HSA made with after-tax dollars can be deducted from your gross income, meaning you may pay less income tax at the end of the year.4�The interest you earn on your HSA funds is not taxed

if the funds are used for qualified medical expenses.4�Withdrawals from your HSA for qualified medical

expenses are not subject to federal income tax. Please refer to the chart at the bottom of the page for more information on qualified medical expenses.

Things to consider when it comes time for tax planning:

4�If you are an active employee and your employer contributes to your HSA, it will be reported on your W-2 form.4�You will receive a 1099 form and a 5498 form in the

mail near tax time so you can file your taxes. You will have to complete an 8889 form when you file your taxes.

Qualified Medical Expenses Examples of Non-allowable Expenses

The IRS allows you to use your HSA funds to pay for “qualified medical expenses” (QME) that may not be covered by your health plan. These expenses include, but are not limited to:

If you use your HSA for nonqualified medical expenses, you can’t deduct these from your gross income and they’re subject to an additional 20% tax penalty (except in the case of payments made after the account holder’s death, disability or turning age 65).

4�Braces 4�Athletic club membership

4�Long-term care premiums 4�Babysitting (for healthy children)

4�COBRA premiums 4�Cosmetics and hygiene products

4�Dental care, except teeth whitening 4�Hair transplant

4�Hearing aids 4�Health programs at resorts, health clubs and gyms

4�LASIK surgery 4�Nutritional supplements

4�Over-the-counter drugs* 4�Premiums for life, disability, other accident insurance

4�Contact lenses 4�Teeth whitening

*Over-the-counter drugs require a prescription from your physician in order to qualify as a QME.

For a complete listing of qualified medical expenses and related information, please refer to IRS Publication 502. You can request a copy by logging in to irs.gov and clicking on “Forms and Publications” or by calling 800-829-3676.

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Funding your HSA is simple

The easiest way is through pre-tax payroll deductions, if allowed by your employer. However, you may also contribute directly to your HSA post-tax, by sending a check to the address printed on your HSA checkbook.

Are you 55 or older? If so, and you are not enrolled in Medicare, you are eligible to contribute an additional amount above the regular limits (referred to as a catch-up contribution). These individuals can make catch-up contributions each year until they enroll in Medicare. For 2013, an additional catch-up contribution of $1,000 is allowed.

Understanding your EOB

Each time you visit a health care provider, you’ll receive an Explanation of Benefits (EOB) from your plan. An EOB is a statement detailing the benefits paid by your health plan and the amount for which you are responsible.

Please save your EOB to reconcile with your HSA statements.

Amount charged by provider — The amount your provider billed Empire for the service.Discounted amount —The negotiated reduction in theamount charged by provider. Charges not covered —Charges that exceed the amount Empire allows for the service or services not covered by your policy.Deductible — The dollaramount you must pay for covered services each year before Empire starts providing coverage. There may be a separate deductible for in-network services and out-of-network services.Coinsurance — The percentageof expenses you pay after your deductible has been met up to your annual out-of- pocket maximum.Copayment — A fixed-dollaramount you pay as your share of the cost of certain services. Often, you pay your copayment at the time you receive care.Payable by Empire — Theamount Empire is paying for your benefits. This amount may be sent to you or your provider. If the payment is made to you, it is your responsibility to ensure that your provider has received payment.Your responsibility — This isthe amount your provider willbill you when you receive yourprovider bill. You can use yourHSA checking account or debitcard to cover your expenses.

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How does your consumer-driven health plan work?

Going to the doctor

Choose a provider from the largest network of doctors nationwide. Approximately 80% of all physicians nationwide are in the BlueCard® PPO program, so you can always find an in-network doctor and possibly save with the lowest negotiated rate.

When you are at the doctor’s office, simply present your Empire BlueCross BlueShield ID card. You usually do not have to pay at the time of service. Once you’ve seen the doctor, the doctor’s office will submit your claim, and the amount you are responsible for will be calculated. You will receive an EOB letting you know how much was paid to the doctor. You decide whether to pay for your share of the doctor’s services from your HSA funds or if you want to pay out of pocket.

By seeing a doctor in the extensive BlueCard® PPOnetwork, you can take advantage of our discounts which may help you save money.

Example: Member goes to in-network doctor’s office

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7Member seeks careat doctor’s officeand pays nothingat the office.

Doctor submitsclaim for office visit for $100.

Empire processes the claim at a discounted rate of $60.

Empire applies the $60 toward the member’s in-network deductible.

Empire sends EOB to doctor.

Empire sends EOB to member indicatingmember responsibility.

Doctor billsmember for $60.*

For illustrative purposes only.

*Member chooses to pay $60 from HSA by check or debit card or from other personal funds to save HSA dollars.

Find a provider that is right for you

Our ProviderFinder allows you to easily search for physicians and health care facilities. With your consumer-driven health plan, going to the doctor is easy. Simply log in to empireblue.com and click on “Find a Doctor.” You can find a doctor or specialist in the PPO network based on the doctor’s location, gender, medical specialty, language spoken and hospital affiliation. Once you answer a few short search criteria questions, you will have access to a provider’s address, phone number and even directions to the location.

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Filling a prescription

When visiting an in-network retail pharmacy, simply present your pharmacy ID card and your prescription. As usual, they will process your claim for you. If you haven’t met your annual deductible, you will be responsible for the discounted price of the medication. The charge for your prescription drug will be applied toward your annual in-network deductible. If you have met your annual deductible, you’ll pay either coinsurance or a copayment depending on the terms of your benefit plan.

You decide whether to pay for the medication from your HSA or to use other funds. If you decide to use HSA funds, you have the flexibility to pay with a check or debit card.

You can also use your HSA funds to pay for over-the-counter medications with a doctor’s prescription that are not covered by your plan. You can learn more about which over-the-counter medications are reimbursable at irs.gov. Refer to your benefit materials for further information.

Example: Member goes to in-network pharmacy

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Member bringsprescription toretail pharmacy.

Pharmacy fills theprescription andprocesses claim at the point of service (e.g., retail price for drug = $62; discount price = $36).

Member owes $36at point of serviceand has the optionto pay from HSAor out of pocket tosave HSA funds.

$36 is appliedtoward member’sannual in-networkdeductible.*

For illustrative purposes only.

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Your plan gives you the tools and the access to determine the health care services that make sense for you and your family. Because you control the funds in your HSA, you can choose to spend or save your HSA funds when you see a doctor, when you have elective surgery or even when you visit an urgent care center or the emergency room. Here are some tips to help you use your health care dollars wisely:

�Visit in-network doctors and specialists. Empire discounts are often a significant percentage of the provider’s charge.4�Get regular preventive care to help avoid more

serious conditions and higher medical costs in the future.4�Ask your doctor if there’s a generic equivalent

available for your brand-name drug listed on the plan’s formulary.4�Ask your doctor to prescribe a drug listed on the plan’s formulary.

Tips on getting the most from your health care dollars

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Going to a hospital

If you need hospital services, you have access to many hospitals across the country through the BlueCard® PPO program.

When you are at the hospital, simply present your ID card. You usually do not have to pay at the time of service for in-network services. The hospital will submit your claim and you will receive an EOB letting you know how much you owe the hospital.

If you have to pay at the hospital, remember that your HSA works like a regular checking account. You should know your balance before you swipe your debit card or write a check.

With your health plan, your costs for covered services are the actual, discounted prices of the services. Once you’ve reached your annual deductible, you will be responsible for the coinsurance amount. By going to an in-network hospital, you can take advantage of discounts and save money.

Note: If you’re going to the hospital for a planned service, you may be required to notify Empire of the admission by calling the number on the back of your member ID card. This way, we can work with your doctor to coordinate your hospitalization and post-hospital care.

360° Health®: Personalized services and online tools for health-conscious consumers

360° Health is our approach to surrounding you with the resources, tools, guidance and support to help you make the right health care decisions for you and your family. Our award-winning, online health site gives you access to tools to help you manage your health. You can learn more about your plan, look up providers, manage your health online, track your health spending and savings, and even customize your own home page on the site:

Manage your health online: Use health tools on the 360° Health page to learn ways to stay healthy, deal with an illness or prepare for a surgical procedure, including questions to ask your doctor.

Track your health spending and savings: Use the My Account page to help you keep track of your health care dollars, claims and benefits.

MyHealth Record: Keep track of your personal health information with MyHealth Record. We’ve made it easy for you to organize and monitor your medical records and plan for future treatments with a single, secure online resource.

Symptom Checker: Find out what may be ailing you. Take advantage of our Symptom Checker to dig up clues about what might be causing those aches, pains and twinges. The Symptom Checker is a good first step, but check with a medical professional for a more accurate assessment.

Plus, personalized services via phone at no additional cost

24/7 NurseLineSM: To help you make informed decisions about your health situation, when you’re not sure if a trip to the doctor or ER is needed.

ConditionCare*: One-on-one assistance at no additional cost from a registered nurse, to help you or a family member manage certain health conditions that require ongoing attention, such as asthma, diabetes or heart disease. BlueCare Consultant*: Support to manage other health conditions – such as hypertension, low back pain or even pregnancy – as well as guidance on overall wellness and assistance to prepare you for an upcoming surgical procedure.

*Availability based on program features included in your plan.

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Frequently asked questions

Q. What if the doctor requests payment at the time of service?

A. If a network provider asks you for payment at the time of service, have your doctor’s office call the number on the back of your ID card.

Q. What happens if I see a doctor not in the plan’s network?

A. If your doctor is not part of the network, you will be responsible for paying the full charge at the time of service, then filing an out-of-network claim.

Q. When are HSA funds available for me to use?

A. Once you activate (or open) your account your HSA funds are available for use as soon as they are deposited into your account. Remember, like a checking account, you can only spend the funds for which you have a sufficient balance. Look for activation instructions in your HSA Welcome Kit.

Q. Can I use HSA funds for nonmedical expenses?

A. If you use your HSA funds for nonqualified expenses, you’ll be required to pay income tax on nonqualified expenses plus a 20% penalty. To check the list of qualified expenses, visit irs.gov.

Q. When and how often can I contribute to my HSA?

A. You can contribute to your HSA at any time during the plan year. Check with your employer for more details on how often you can contribute to your HSA.

Q. Can I contribute to both an HSA and FSA?A. If your employer offers both, you may

contribute to both; however, if you have both, your flexible spending account (FSA) must be a “limited purpose” account and can be used only for dental, vision or post-deductible expenses. The type of FSA is determined by your employer.

Q. What happens to the money in my HSA if I leave my job?

A. The funds in your HSA are yours and can be used even if you leave your job. If your new employer offers a qualified high-deductible plan, you may continue to contribute to your HSA.

Q. Are there adjustments to the HSA for

inflation?A. Every year, the IRS adjusts HSA maximum

allowable contribution amounts to account for inflation. Your health plan and your employer will provide you updated amounts during your Open Enrollment period.

Q. What happens if I contribute more than the

maximum amount allowed in a given tax year?

A. You may withdraw the excess without penalty up until April 15 of the following year. After that time, you would need to pay both income tax and an excise tax. Consult your tax advisor for details.

Q. What happens to my HSA if I am no longer

covered by a high-deductible health plan?A. You can continue to spend your HSA dollars

on qualified medical expenses. However, you cannot continue to contribute to your HSA. You must be covered by a qualified high-deductible plan in order to contribute to and receive tax benefits on your HSA.

Q. Can my spouse have an HSA?A. If your spouse is covered by a qualified high-

deductible plan and is not covered by your health insurance, he or she may be eligible for an individual HSA.

Q. Can my HSA be used for dependents not

covered by medical insurance?A. Yes, your HSA funds may be used to cover

qualified medical expenses incurred by dependents not covered by your medical insurance.9

Unmatched service excellence

One call to your service representative does it all

A commitment to customer service

Our Member Services representatives will coordinate and follow up with doctors, hospitals and other parties to help resolve any questions you may have.

With one call to Member Services, you’ll also be able to get assistance with claims, find doctors, get your HSA balance and, if necessary, be connected to your HSA financial institution.

In addition, our website, empireblue.com allows you to manage your health plan with simplicity and flexibility. You can order an ID card, print forms, view service history and receive personalized messages from Empire in your Message Center.

You can also contact a Member Services representative online via e-mail or a call back.Few things are more personal than your health. Your personal home page on empireblue.com is accessible only to you through the login ID and password that you select when you register for Member Online Services.

If you have any questions or concerns after reading this material, please call us at the phone number listed on your ID card Monday through Friday, or contact your benefit administrator for more information.

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24/7 service at your fingertips

Here’s a sampling of what you can do online tobecome a more informed health care consumer:4�View a summary of your plan benefits (including

medical benefits, copays, deductibles, coinsurance, hospital benefits and more)4�Access your HSA balance and transaction

history – including a record of deposits and withdrawals4�Participate in online classes at no additional

cost and get personalized health information

Why should a health plancare about your health?

The fact is that good health not only feels better, it may cost less, too. Doing what’s best for your health is not a short-term fix; it’s a long-term solution. And over the long term, living a healthier life can help you save money. Empire Total Blue with Health Savings Account is designed to help you do both.

empireblue.com

Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. 360° Health is a registered trademark of Anthem Insurance Companies, Inc.

14332NYMENEBS 11/12

BNY Mellon HSA Banking Fees

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April 30, 2012

Description of Fee Charge (subject to change) Notes

Monthly Account Maintenance No charge If an employee leaves the company-sponsored plan but retains the HSA, charge is $3.25 per month.

Employee Monthly Investment Account Fee

$2.90 per month Applies if employee invests HSA funds into one (or more) of the ACS/Mellon mutual fund options

Account Closure / Rollover Fee $25.00

Account Termination Fee $25.00 No charge if consumer writes check for account balance.

Additional Copy of Tax Form $5.00

Cash Advance Fee Not applicable Cash advances are not allowed with the debit card.

Check Reorder Fee $10.00

Check Writing Fee (per check) No charge

Copy Check / Statement $5.00

Debit Card – ATM withdrawal $1.00 per transaction

Debit Card Replacement Fee / Additional Card Fee

$5.00 Fee applicable with each replacement or additional card.

Debit Card Transactions No charge

Deposit – Uncollected Funds $25.00

Duplicate Check Fee $5.00

Excess Contribution Refund $25.00

Mailing Additional Forms No charge

Merchant Debit Card Receipt Copy No charge

Monthly Statement – Paper $0.75 Fee is waived if member chooses to view statements online

Overdraft Fee $25.00

Returned Check Fee $25.00

Stop Payment Fee $25.00

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Description of Fee Charge (subject to change) Notes

Teller Withdrawal (per occurrence) Not applicable Cash advances are not allowed with the debit card.

Wire Transfer Sent & Received Not applicable Wire transfers not offered to consumers.

Aggregate deposit by ACH, wire or check, plus FTP file transmission of account information in Mellon standard flat file.

No charge

Aggregate deposit by ACH, wire or check, plus file transmission of account information in Mellon standard MS-Excel file.

No charge

Aggregate deposit by ACH, wire or check, plus list of account information (not electronic and/or not complying with Mellon standard layouts in the above methods).

No charge

Deposit by automated clearinghouse (ACH) directly into individual HSA accounts.

No charge