Key Features

Use the filter to find information for the coverage level you want:

• Employee Only
• Employee + One
• Employee + Family

COVERAGE LEVEL	IN NETWORK	OUT OF NETWORK*
Employee Only
Your Biweekly Contribution	$40.22	$40.22
Deductible	$1,650	$3,300
Hess HSA Contribution	$500	$500
Your HSA Contribution	Up to $3,800 ($4,300 IRS limit minus Hess contribution)	Up to $3,800 ($4,300 IRS limit minus Hess contribution)
Out-of-Pocket Maximum	$3,000	$6,000
EMPLOYEE ONLY

_{* Out-of-network expenses are limited to the eligible maximum allowed amount. You are responsible for paying any amount over the eligible maximum allowed amount charges in addition to your deductible and coinsurance.}

COVERAGE LEVEL	IN NETWORK	OUT OF NETWORK*
Employee + One
Your Biweekly Contribution	$80.43	$80.43
Deductible	$3,300	$6,600
Hess HSA Contribution	$1,000	$1,000
Your HSA Contribution	Up to $7,550 ($8,550 IRS limit minus Hess contribution)	Up to $7,550 ($8,550 IRS limit minus Hess contribution)
Out-of-Pocket Maximum	$6,000	$12,000
EMPLOYEE + ONE

_{* Out-of-network expenses are limited to the eligible maximum allowed amount. You are responsible for paying any amount over the eligible maximum allowed amount charges in addition to your deductible and coinsurance.}

COVERAGE LEVEL	IN NETWORK	OUT OF NETWORK*
Employee + Family
Your Biweekly Contribution	$137.52	$137.52
Deductible	$3,300	$6,600
Hess HSA Contribution	$1,000	$1,000
Your HSA Contribution	Up to $7,550 ($8,550 IRS limit minus Hess contribution)	Up to $7,550 ($8,550 IRS limit minus Hess contribution)
Out-of-Pocket Maximum	$6,000	$12,000
EMPLOYEE + FAMILY

_{* Out-of-network expenses are limited to the eligible maximum allowed amount. You are responsible for paying any amount over the eligible maximum allowed amount charges in addition to your deductible and coinsurance.}