text – Quick Find View – Hess Benefits

Vision Plan Features

	IN NETWORK	OUT OF NETWORK
Covered Services Every 12 Months
Annual Exam	100%, no copay	$40 allowance
Frames	$130 allowance; 20% discount	$45 allowance
Lenses*
Single Vision	100% after $35 copay	$25 allowance
Bifocal	100% after $35 copay	$40 allowance
Trifocal	100% after $35 copay	$55 allowance
Lenticular	100% after $35 copay	$75 allowance
Contacts (IN PLACE OF LENSES)
Elective Conventional	$200 allowance; 15% discount	$105 allowance
Elective Disposable	$200 allowance	$105 allowance
Non-Elective	100%	$210 allowance
Contact Lens Fitting	100%	Not covered

_{* Options such as extra-thin lenses or special lens coatings may increase your out-of-pocket costs.}

COST PER PAYCHECK

Prescription Drug Details

Here’s What the Plan Pays

	IN NETWORK	OUT OF NETWORK
Preventive Retail & Mail Order
Generic	100%	60% after deductible
Branded	85%	40% after deductible
Non-Preventive Retail & Mail Order
Generic	85% after deductible	60% after deductible
Branded	85% after deductible	40% after deductible

How Services Are Covered

	IN NETWORK	OUT OF NETWORK*
Here's What the Plan Pays
Preventive Care**	100% no deductible	65% after deductible (after $500 annual allowance)
Office Visits Primary Care Specialist	85% after deductible	65% after deductible
Emergency Room	85% after deductible	85% after deductible
Hospital	85% after deductible	65% after deductible
Laboratory	85% after deductible	65% after deductible
X-Ray	85% after deductible	65% after deductible
Knee, Hip and Spine Procedures at Anthem Blue Distinction Centers	90% after deductible	No coverage

_{* 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.}

Key Features

	IN NETWORK	OUT OF NETWORK*
Employee Only
Your Biweekly Contribution	$37.80	$37.80
Deductible	$1,400	$2,800
Hess HSA Contribution	$500	$500
Your HSA Contribution	Up to $3,100 ($3,600 IRS limit minus Hess contribution)	Up to $3,100 ($3,600 IRS limit minus Hess contribution)
Out-of-Pocket Maximum	$2,750	$5,000
Employee + One
Your Biweekly Contribution	$75.59	$75.59
Deductible	$2,800	$5,600
Hess HSA Contribution	$1,000	$1,000
Your HSA Contribution	Up to $6,200 ($7,200 IRS limit minus Hess contribution)	Up to $6,200 ($7,200 IRS limit minus Hess contribution)
Out-of-Pocket Maximum	$5,500	$10,000
Employee + Family
Your Biweekly Contribution	$129.24	$129.24
Deductible	$2,800	$5,600
Hess HSA Contribution	$1,000	$1,000
Your HSA Contribution	Up to $6,200 ($7,200 IRS limit minus Hess contribution)	Up to $6,200 ($7,200 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 co-insurance.}

What Happens if You Don’t Enroll?

Your current elections will continue automatically except for:

Health Savings Account (HSA)—Your current election will not carry over, so you’ll need to elect an amount to contribute in 2021. You can do this during Benefits Open Enrollment or anytime in 2021.
Dependent Care Flexible Spending Account (DCFSA)—You must enroll during Benefits Open Enrollment if you want to contribute for 2021. Otherwise, changes are only allowed if you have a qualified life event.

Qualified Life Events Include:

Birth, adoption or placement for adoption
Marriage
Divorce, legal separation or annulment
Death of a dependent
Change in employment status for your spouse

You must make any changes to your medical, dental and/or DCFSA benefits within 30 days of your qualified life event, and your change must be consistent with your life event. If you miss this window, you will have to wait until the next Open Enrollment period to make changes.

To make a qualified life event change during the year, contact the Hess Benefits Center at Empyrean.

What You Need to Do to Enroll

Know the Enrollment Deadline

For medical, dental, optional life insurance and family accident insurance coverage, as well to contribute to a dependent care FSA, you must enroll within 30 days of when you become eligible.

You will be automatically enrolled in long-term disability insurance, basic life insurance and business travel accident insurance, as well as the savings and pension plan. If you don’t enroll in the savings plan, you will be automatically enrolled after 30 days of employment.

If you enroll in the Hess Medical Plan, you can establish a Health Savings Account (HSA) when you enroll for medical coverage or anytime afterwards.
Decide Who to Cover

You can enroll yourself and your family in Hess benefits. Be sure you know who’s eligible before you choose coverage.

You are eligible if you are a full-time employee.

You may also cover members of your family. Eligible dependents are:
- Your spouse
- Your same- or opposite-gender domestic partner
- Your children through the end of the calendar year in which they reach age 26. Eligible children include:
  - Your natural and adopted children (including children placed with you for adoption)
  - Stepchildren who live with you
  - Disabled children (of any age)
  - Children for whom you have legal guardianship
  - Children of your same- or opposite-gender domestic partner

Review Your Choices

What you can choose	What Hess provides _{(No enrollment required)}
Medical (includes Rx and Vision)	Short-Term Disability Long-Term Disability
Dental	Basic Life Insurance
Family Accident Insurance	Business Travel Accident Insurance
Optional Life Insurance for you, your spouse and/or dependents	Savings Plan (After 30 days of employment if not enrolled earlier)
Dependent Care FSA	Pension Plan
Health Savings Account
Voluntary Benefits including: Accident Insurance, Critical Illness Insurance and Identity Theft Protection

You can also review your 2021 Hess Benefits Decision Guide for details you need to choose your benefits. We encourage you to review all of your options.

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