The HSA Quarterly Health Statement: A Brief Overview As an Anthem member, you receive a quarterly health statement. The health statement gives you a comprehensive view of how you’re spending your health care dollars. Below is a sample quarterly health statement for the Lumenos® with Health Savings Account (HSA) plan, along with an overview of the information that’s provided in the statement. 1 Summary of Annual Benefit Maximum Contribution Allowed: Reminds HSA STANDARD Anthem, FOH13-MB,OH25A-203 1351 WM Howard Taft Cincinnati, OH 45206 SAMPLE Your Quarterly Health Plan Status For the period from January 1, 2011 to March 31, 2011 Account Holder: Joe Consumer Health Program ID: WEP9998817749004 JOE CONSUMER 300 MAIN STREET ALEXANDRIA, VA 22314 Group: 9999wf99r9 Coverage Type: Single Date Prepared: 04/11/2011 You can also view this statement online. Log on to anthem.com for more details 1 Summary of Annual Benefit For Coverage Effective 01/01/2011 Maximum Contribution Allowed for Tax Year 2011: $ Annual Out-of-Pocket Maximum Amounts: In-Network: Out-of-Network: 6,150.00 Your Annual Deductible*: $ 3,000.00 Amount accumulated towards Annual Out-of-Pocket Maximum: In-Network: Out-of-Network: $ $ 250.00 0,000.00 $ 6,000.00 $ 12,000.00 *Your deductible is the annual amount you pay before you reach the coinsurance portion of the plan. 2 Plan Status (Benefit Year to Date) Amount paid to satisfy deductible: $ 250.00 Log on to anthem.com for your most up-to-date HSA balance information. 3 Summary of How Your Health Care Dollars Were Spent (Benefit Year to Date) Service Type Preventive care Non-preventive care Medical expenses Brand name drugs Generic drugs RX expenses Total expenses $ $ $ $ $ $ $ Amount 600 250.00 175.00 425.00 50.00 25.00 75.00 500.00 500 300 200 100 Preventive care Non-preventive care Brand name drugs Generic drugs Total expenses 3 Summary of How Your Health Care Dollars 24934381200 Were Spent This section provides a quick snapshot of how your health care dollars were applied towards general categories of types of services received year to date. Page 1 of 4 18049ANMENABS 11/10 For additional information, please contact Member Services. MANSH6813A Rev. 12/10 Your Annual Deductible: This is the amount you must pay, from your HSA or out-of-pocket, before your insurance begins to cover any of your expenses. Annual Out-of-Pocket Maximum: This is the maximum amount you will pay out of pocket for the year for network and out-of-network medical (e.g., doctor and hospital visits) and prescription expenses. Once you have reached this amount, you won’t have to pay anything for covered services for the remainder of the plan year. 2 Plan Status Amount paid to satisfy deductible: The amount you’ve paid (year to date) toward meeting your annual deductible. 400 0 you of how much you’re allowed to contribute to your HSA during the course of the year, as determined by the IRS. Amount accumulated toward Annual Out-of-Pocket Maximum: Shows the amount you’ve spent (year to date) toward reaching your Out-of-Pocket Maximum. The HSA Quarterly Health Statement: A Brief Overview Below is a sample of additional components you will find on a quarterly health statement for the Lumenos with Health Savings Account (HSA) plan, along with an overview of the information the statement provides you. 4 Summary of Recent Health Plan Activity HSA STANDARD SAMPLE Your Quarterly Health Plan Status For the period from January 1, 2011 to March 31, 2011 4 Summary of Recent Health Plan Activity (01/01/20 to 03/31/2011) Claim Activity Total Member Responsibility for Claims: 5 $ Amount Saved by Choosing Participating Network Providers: 250.00 $ 240.11 Health Plan Activity Details (01/01/20 to 03/31/2011) Posted Date Member Name Description Claim Number Amount (+/-) Plan Paid* Your Resp ** 03/07/11 03/09/11 Joe Consumer Smith, John MD XXXXXXXXX $175.00 $0.00 02/23/11 02/26/11 Joe Consumer Allenville Pediatrics XXXXXXXXX $250.00 $250.00 $0.00 02/23/11 02/26/11 Joe Consumer Pharmacy XXXXXXXXX $50.00 $0.00 $50.00 03/26/11 03/31/11 Joe Consumer Pharmacy XXXXXXXXX $25.00 ToTAl This Period $175.00 $0.00 $25.00 $250.00 $250.00 * Is the amount paid toward coinsurance, preventive care and/or covered medical expenses. ** Is the amount you owe. The doctor or facility will bill you for this amount. 6 Amount Saved by Choosing Participating Network Providers: Shows the amount you saved, this quarter, by visiting providers in the Blue Cross Blue Shield network. 5 Health Plan Activities Details The following transactions were processed during the statement period. Additional detail is available at anthem.com. Once you log in, click on “Plans and Benefits” to view transactions. Service Date Total Member Responsibility for Claims: Shows the amount you’ve paid from your HSA or out-of-pocket for services received this quarter. This section shows a breakdown of the claims received throughout the quarter, including the amount billed, how much was covered by traditional health coverage and how much you’re responsible for paying. If you’re responsible for any expenses, you’ll receive a bill for services from your provider. Making the Most of My Plan Diagnosis codes from your doctors show that you had a heart attack in the past. For most people, a type of medication called a beta blocker can lower your chances of having another heart attack. We encourage you to communicate with your doctor about this suggestion to see if a beta blocker is right for you. It is currently recommended that people obtain certain blood tests 3 months after starting Lipitor. These tests will re-check your cholesterol and liver function. We have not received a bill from a laboratory that shows you have had these tests. We recommend that you communicate with your doctor about the suggestion (55). 6 Making the Most of My Plan This section provides personalized tips on ways you can improve your health and/or take better advantage of the benefits offered through your health plan. Using generic drugs reduces the amount you pay for your prescriptions. Recently, you filled a prescription for Proventil and paid a discounted price of $65.00. Albuterol is a generic form of Proventil. If you use Albuterol, your estimated discount cost would be only $7. By switching, you could save $395 per year. Talk to your doctor about whether you can make this switch and start saving money. Using generic drugs reduces the amount you pay for your prescriptions. Recently, you filled a prescription for Proventil and paid a discounted price of $65.00. Albuterol is a generic form of Proventil. If you use Albuterol, your estimated discount cost would be only $7. By switching, you could save $395 per year. Talk to your doctor about whether you can make this switch and start saving money. 24934381200 Page 2 of 4 18049ANMENABS 11/10 For additional information, please contact Member Services. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado and Nevada: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (“BCBSWi”), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (“Compcare”), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM and LUMENOS are registered trademarks of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.