ROLLOVER/TRANSFER

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Note: This process is subject to change.Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.

On behalf of Blue Cross and Blue Shield of North Carolina

DIRECTIONINFORMATION

helpful&

Why transfer/rollover your money? 3

Transfer credit 4

Transfer vs. rollover 4

Transferring your HSA dollars 5

Rollover your HSA dollars 5

HealthEquity Transfer Form 6

HealthEquity Rollover Request Form 7

Questions 8

Table of Contents

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WHY TRANSFER OR ROLL OVER YOUR MONEY?

Convenience:Through your Blue Cross and Blue Shield of North Carolina (BCBSNC) high deductible health plan, you can benefit from a fully integrated HSA, administered by HealthEquity. With all your funds available in a single account, you can more easily track all of your contributions, distributions and tax reporting.

Avoid fees:As a BCBSNC HSA plan member, your monthly admin fees are covered. Moving your HSA balance to HealthEquity will help you avoid monthly fees with your current HSA administrator going forward.

Get rewarded:• Earn double interest up to $25 for transfers or

rollovers of $250 or more.

• See terms and conditions listed on page 4.

Investment options:You can begin investing when you have a $2,000 minimum balance; transferring your HSA balance will allow you to invest sooner. A wide array of mutual funds with no investment transaction fees are available and can help you plan for medical expenses now and in the future.

your

HSA

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Transfer creditHow to request the transfer or rollover:Transfers:

Fill out the HealthEquity Transfer Form on page 6.

Submit the completed form via fax or mail to HealthEquity per the instructions on the form on page 6.

You should see the transferred amount in your new HealthEquity account within 3-6 weeks from the date the form is submitted. It may take two business days from the time the funds are posted to be available for use.

Rollovers: Review instructions on Page 5. Fill out the HealthEquity Rollover Form on page 7. Send your completed form to HealthEquity.

Your rollover will be posted within two business days of receipt and made available after another 5 business days.

Terms and conditions:• To receive double monthly interest up to $25 you need to transfer/ rollover a balance of $250 or greater.

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Transfervs.

RolloverTransferFor transfers, your current HSA administrator will process your request as a Trustee-to-Trustee transfer and send a check for you directly to HealthEquity. Please check with your current HSA administrator regarding any closure fees that may apply. The funds should be received and available within 3-6 weeks. No tax form will be issued by either party since the transaction is simply a balance transfer.

RolloverIf you have already closed your prior HSA and received your final HSA distribution, you can send it to HealthEquity as a rollover to your new HSA as long as it has been less than 60 days since receiving your distribution. You can only request one rollover every 12 months. A 1099-SA tax form will be issued by your prior HSA custodian to report the distribution and a 5498-SA tax form will be issued by HealthEquity to report the rollover.

We invite you to receive $25 in credit for moving your existing health savings account (HSA) balance to HealthEquity

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Transferring your HSA dollars is easy. Complete the steps on this form and your current HSA administrator will send a check to HealthEquity.

Liquidate any investment assets you may have with your current HSA administrator.

Complete the HealthEquity Transfer Form listed on page 6.

Mail or fax your form to HealthEquity.

Receive your funds into your HealthEquity HSA in 3-6 weeks.

Remember, HealthEquity’s transfer credit is helping you offset up to $25 in closure fees which may be assessed by your current HSA administrator.

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Transferring your HSA dollars

Rollover your HSA dollarsHere are some simple steps to complete an HSA rollover to HealthEquity.

Liquidate any investment assets you may have with your current HSA administrator.

You must complete your current HSA administrator’s closure form and submit it to them per their instructions.

Include the HealthEquity Rollover Request form located on page 7 with the check you receive from your prior HSA administrator.

Mail your check and form to HealthEquity. Send to the address on the top of HealthEquity’s Rollover Request Form.

Remember, HealthEquity’s transfer credit is helping you offset up to $25 in closure fees which may be assessed by your current HSA administrator.

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Transfer Request Form Email, mail or fax completed forms to:Email: transfer@healthequity.comAddress: HealthEquity,Attn:Operations

15 W Scenic Pointe Dr, Ste 100, Draper, UT 84020 Fax: 520.844.7090

Use the transfer request form to transfer monies directly from another custodian into your HealthEquity® HSA. *Required fields

Part I—PrimaryAccountHolderInformationLast Name* First Name* M.I. Gender

c Male c FemaleDate of Birth*

Street Address* City* State* ZIP*

Email Address Daytime Phone( )

SSN or HealthEquity ID Number* (6 or 7 digits)

Employer Name Health Insurance Company Coverage Levelc Single c Family

Deductible Amount$

PartII—TransferInformation

This request is for a custodian-to-custodian transfer or an employer-to custodian transfer. The monies currently held by another custodian are to be directly transferred to an HSA at HealthEquity. Note: Your current custodian may require additional information prior to sending HealthEquity the funds you are requesting. Please contact them to verify the additional information they may need.Current Custodian/Financial Institution* Current Custodian Fax

( )Daytime Phone( )

Address City State ZIP

Current HSA/IRA/MSA Account Number Amount to Transferc Specific Amount $ c Full Amount (close my account)

Please indicate the account type that the monies will be coming from. (See rules and conditions for account types below.)

c IRA1 (individual retirement account) c MSA2 (medical savings account) c Another HSA2 (health savings account)

CurrentCustodianInstructionsMake check payable to HealthEquity and mail it to: HealthEquity,Attn:Operations, 15 W Scenic Pointe Dr, Ste 100, Draper, UT 84020

AuthorizationI authorize the transfer of assets in the manner described above and certify that all of the information provided by me is true and complete. This transfer request may close my existing account defined in the Amount to Transfer section. I authorize HealthEquity to open a Health Savings Account in my behalf and I accept the terms of the HealthEquity HSA Custodial Agreement available at http://resources.healthequity.com/Forms/Agreements/HealthEquity_Custodial_Agreement.pdf. I understand that in compliance with the USA Patriot Act, HealthEquity must verify the identity of all individuals who seek to open an HSA. I understand that as part of this identity verification process, I may be asked to provide additional information and/or documentation before my account can be established.Account Holder Signature* Date

Transfers1IRA—Beginning in 2007, individuals can make one lifetime transfer from their IRA to an HSA, subject to the contribution limits applicable for the year of the transfer. Additional information can be found at www.irs.gov. 2HSA/MSA—If you instruct the custodian of your HSA or MSA to transfer funds directly to the custodian of another HSA, the transfer is not considered a rollover. There is no limit on the number of these transfers. You do not need to include the amount transferred in income, deduct it as a contribution, or include it as a distribution on IRS Form 8889, line 12a.

Transfer_Request_Form_20151019

Move It. Double It.Get double interest on your HealthEquity® HSA. Just transfer or roll over $250 or more from another HSA to HealthEquity and get up to $25 total. Get full details at www.healthequity.com/DoubleInterest.www.healthequity.com 866.346.5800

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Rollover Request Form Mail or fax completed forms to:Address: HealthEquity,Attn:ClientServices

15 W Scenic Pointe Dr, Ste 100, Draper, UT 84020 Fax: 520.844.7090

Use the rollover request form to roll over funds into your HealthEquity® HSA that have already been distributed to you from another custodian.

PrimaryAccountHolderInformationLast Name First Name M.I. Gender

c Male c FemaleDate of Birth

Street Address City State ZIP

Email Address Daytime Phone( )

SSN or HealthEquity ID Number (6 or 7 digits)*

Employer Name Health Insurance Company Coverage Levelc Single c Family

Deductible Amount$

RolloverInformation

Pleasespecifydollaramounttorollover* $

BankingInformation*(Ifnooptionisselected,formisvoid.)

c Option1—CheckI have included a check for the amount of the distribution from another HSA. Please make check payable to HealthEquity.When you provide a check as payment, you authorize HealthEquity to either use the information from your check to make a one-time, Back Office Conversion (BOC), electronic fund transfer from your account if eligible, or to process the payment as a check transaction. Funds processed via BOC may be withdrawn from your account as soon as the same day your payment is received.

c Option2— Use verified EFT account already on file associated to my HSA. Please provide last 4 of account number .*Note: Account must be verified for contributions in order for HealthEquity to pull the funds via EFT.

c Option3—One-time electronic funds transfer (EFT). (Formmustbeaccompaniedbyacopyofavoidedoranactualcheck)

Authorization

I authorize HealthEquity to open a Health Savings Account in my behalf and I accept the terms of the HealthEquity HSA Custodial Agreement available at http://resources.healthequity.com/Forms/Agreements/HealthEquity_Custodial_Agreement.pdf. I understand that in compliance with the USA Patriot Act, HealthEquity must verify the identity of all individuals who seek to open an HSA. I understand that as part of this identity verification process, I may be asked to provide additional information and/or documentation before my account can be established.Account Holder Signature (required) Date

RolloversA rollover is a way to move money or property from a medical savings account (MSA) or existing health savings account (HSA) to a HealthEquity HSA. The Internal Revenue Code (IRC) limits how many rollovers may be taken, how quickly rollovers must be completed, and how the custodian must report the transaction.

1. TimelinesThe funds you receive from an MSA or HSA must be deposited into an HSA within 60 days of receiving them. When counting the 60 days, include weekends and holidays. Receipt generally means the day you actually have the funds in hand. For example, the 60 days would begin on the day you pick up the check from the Custodian or you receive the check in the mail. The 60 day rule is set by the IRS and cannot be changed by HealthEquity.

2.Twelve-MonthRestrictionYou are entitled to one distribution per year per HSA, which may be rolled over to another HSA. Twelve (12) months must pass after receipt of one rollover before you may make another distribution from the same HSA to rollover.

Note:Incompleteformswillnotbeprocessed.Insuchcases,wewillattempttocontactyouviaemailorphonetoadvisethattheformwasmissinginformation.

Rollover_Request_Form_20150925

*Required fields

Move It. Double It.Get double interest on your HealthEquity® HSA. Just roll over $250 or more from another HSA to HealthEquity and get up to $25 total. Get full details at www.healthequity.com/DoubleInterest.

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Expert friendsHelpful support for our members, available every hour of every day

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QUESTIONS?If you have any questions, HealthEquity Member Education specialists are available every hour of every day at 877.713.7682.

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15 West Scenic Pointe Drive, Suite 100Draper, UT 84020

www.HealthEquity.com

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Blue Cross and Blue Shield of North Carolina (BCBSNC) does not administer your HSA and is not affiliated with your HSA custodian or administrator. HealthEquity, Inc. is an independent entity that provides HSA custodial services. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.

Nothing in this communication is intended as legal, tax, financial, or medical advice. Always consult a professional when making life changing decisions. In addition to restrictions imposed by law, your employer may limit what expenses are eligible for reimbursements. It is the members’ responsibility to ensure eligibility requirements as well as if they are eligible for the plan and expenses submitted.