Pelican HRA 1000
Administered by Blue Cross Blue Shield
- Nationwide Coverage
- 2020 Summary of Benefits
The Pelican HRA1000 includes $1,000 in annual employer contributions for employee-only plans and $2,000 for family plans in a health reimbursement arrangement that can be used to offset deductibles and other out-of-pocket medical, not pharmacy, costs throughout the year.
The HRA funds are available as long as you remain employed by an OGB-participating employer. Any unused funds roll up to the in-network, out-of-pocket maximum (see following chart), allowing members to build up balances that cover eligible medical expenses.
|Employee Only||Employee + 1 (Spouse or Child)||Employee + Children||Family|
|Employer Contribution to HRA||$1,000||$2,000||$2,000||$2,000|
|Out-of-pocket max (in-network)||$5,000||$10,000||$10,000||$10,000|
|Out-of-pocket max (out-of-network)||$10,000||$20,000||$20,000||$20,000|
|Tier||Member Responsibility||Once you pay $1,500|
|Generic||50% up to $30||$0 co-pay|
|Preferred||50% up to $55||$20 co-pay|
|Non-Preferred||65% up to $80||$40 co-pay|
|Specialty||50% up to $80||$40 co-pay|
*Once a member's deductible for allowable charges is met, he or she will pay 40% of the allowable charge, plus 100% of the difference between the allowable charge and billed amount.
At times you may have to pay out of pocket for medical services or for prescriptions, particularly if you have received services from a non-network provider. In the event that you do pay out of pocket for services, you can be reimbursed for these services. You will need to complete and submit a claim form and a copy of the invoice to the appropriate carrier. You may submit a claim form (see below) along with a copy of the invoice to your health insurance carrier. BCBS will then reimburse you according to the plan's guidelines.