Health Savings Account Claim Examples * Single Coverage John goes for his annual physical, including routine lab (blood work to check cholesterol levels and routine exam) Total Charge = $750 Plan Pays $750 (in- or out-of-network) John Pays $0 Claim Example 2a John is hospitalized at an in-network facility for 2 days. He had not met his single deductible of $1,500 yet for the plan year. Total Charge = $6,000 John Pays $1,500 (Deductible) Balance $4,500 John Pays $900 (20% of balance) Total out-of-pocket cost met by John is $2,400 ($1,500 + $900 ) The $2,400 will count toward John’s calendar year in-network, out-of-pocket maximum of $3,000. He can use his Foth HSA Outcome-based Wellness Incentive contribution to offset his out-of-pocket costs. Claim Example 2b John is hospitalized again in the same plan year, at an in-network facility for 3 days. He had already met his single deductible of $1,500. He has already paid $2,400 out-of-pocket, with a remaining $600 to reach the $3,000 maximum. Total Charge = $8,000 (20%=$1,600) John Pays $600 (to reach $3,000 max) Plan Pays $7,400 (remaining balance) For the remainder of the calendar year, the plan will pay 100% of allowable medical and prescriptions charges due to John having met his out-of-pocket maximum. Reminder: Use your medical card when purchasing prescriptions! Note: Any expenses John paid, either in deductible or in co-insurance, can be paid using money reserved in his Health Savings Account (HSA). * Claim examples assume total charge already reflects the provider discount and in-network level of benefits. The examples do not reflect actual fees and are used only as hypothetical claim cases.

Health Savings Account Claim Examples * Family Coverage Diane’s family (3 people) go for their annual physicals, including routine lab (blood work to check cholesterol levels and routine pap test) and immunizations (for the children) Total Charges = $1,500 Plan Pays $1,500 (in-or out-of-network) Family Pays $0 Claim Example 2a Diane’s family (4 people) have two hospitalizations within the calendar year, both at an in-network facility. Neither family member met any of the family deductible of $3,000 yet for the plan year. Total Charges = $10,000 Family Pays $3,000 (Deductible) Balance $7,000 Family Pays $1,400 (20% of balance) Total out-of-pocket cost met by Diane’s family is $4,400 ($3,000 + $1,400) The $4,400 will count toward Diane’s calendar year in-network, out-of-pocket maximum of $6,000. Diane can use her Foth HSA Outcome-based incentive to offset the out-of-pocket costs. Claim Example 2b Diane’s spouse and child have out-patient surgeries in the same plan year, both at in-network facilities. The $3,000 family deductible is met. They have paid $4,400 in out-of-pocket expenses ($1,600 yet to meet out of the $6,000 maximum). Total Charges = $25,000 (20%=$5,000) Family Pays $1,600 (to reach $6,000 max) Plan Pays $23,400 (remaining balance) For the remainder of the calendar year, the plan will pay 100% of allowable medical and prescriptions charges due to Diane’s family having met their out-of-pocket maximum. Reminder: Use your medical card when purchasing prescriptions! Note: Any expenses Diane’s family paid, either in deductible or in co-insurance, can be paid using money reserved in Diane’s Health Savings Account (HSA). * Claim examples assume total charge already reflects the provider discount and in-network level of benefits. The examples do not reflect actual fees and are used only as hypothetical claim cases.