Page 5 - 2019 Hess Benefits Decision Guide

The Hess Medical Plan
Key Features...
YOUR BIWEEKLY CONTRIBUTION
DEDUCTIBLE
HESS HSA CONTRIBUTION
OUT-OF-POCKET MAXIMUM
YOUR BIWEEKLY CONTRIBUTION
DEDUCTIBLE
HESS HSA CONTRIBUTION
OUT-OF-POCKET MAXIMUM
YOUR BIWEEKLY CONTRIBUTION
DEDUCTIBLE
HESS HSA CONTRIBUTION
OUT-OF-POCKET MAXIMUM
How Services Are Covered...
$37.80
$375
$75.59
$750
$129.24
$750
$2,700
$5,000
$5,400
$10,000
$5,400
$10,000
65% after deductible (after $500 annual allowance)
85% after deductible
60% after deductible 40% after deductible
60% after deductible 40% after deductible
IN NETWORK
OUT OF NETWORK*
Employee Only
$1,350
YOUR HSA CONTRIBUTION
Up to $3,125 ($3,500 IRS limit minus Hess contribution)
Employee + One
$2,750
$2,700
YOUR HSA CONTRIBUTION
Up to $6,250 ($7,000 IRS limit minus Hess contribution)
Employee + Family
$5,500
$2,700
YOUR HSA CONTRIBUTION
Up to $6,250 ($7,000 IRS limit minus Hess contribution)
$5,500
PREVENTIVE CARE**
EMERGENCY ROOM
PRESCRIPTION DRUGS
Preventive Retail & Mail Order
Generic
Branded
Non-Preventive Retail & Mail Order
Generic Branded
IN NETWORK
OUT OF NETWORK*
100%
OFFICE VISITS
Primary Care Specialist
85% after deductible 85% after deductible
65% after deductible 65% after deductible
85% after deductible
HOSPITAL LABORATORY X-RAY
85% after deductible
65% after deductible
100% 85%
85% after deductible 85% after deductible
*
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 co-insurance.
** Preventive care includes wellness visits for children, preventive exams and recommended screenings for adults and immunizations
in or out of network.
MEDICAL 3