Key Features – Hess Benefits

	IN NETWORK	OUT OF NETWORK*
Employee Only
Your Biweekly Contribution	$40.22	$40.22
Deductible	$1,400	$2,800
Hess HSA Contribution	$500	$500
Your HSA Contribution	Up to $3,150 ($3,650 IRS limit minus Hess contribution)	Up to $3,150 ($3,650 IRS limit minus Hess contribution)
Out-of-Pocket Maximum	$2,750	$5,000
Employee + One
Your Biweekly Contribution	$80.43	$80.43
Deductible	$2,800	$5,600
Hess HSA Contribution	$1,000	$1,000
Your HSA Contribution	Up to $6,300 ($7,300 IRS limit minus Hess contribution)	Up to $6,300 ($7,300 IRS limit minus Hess contribution)
Out-of-Pocket Maximum	$5,500	$10,000
Employee + Family
Your Biweekly Contribution	$137.52	$137.52
Deductible	$2,800	$5,600
Hess HSA Contribution	$1,000	$1,000
Your HSA Contribution	Up to $6,300 ($7,300 IRS limit minus Hess contribution)	Up to $6,300 ($7,300 IRS limit minus Hess contribution)
Out-of-Pocket Maximum	$5,500	$10,000

_{* 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.}