Pelican HSA 775
Administered by Blue Cross Blue Shield
- Nationwide Coverage
- 2020 Summary of Benefits
The Pelican HSA775 offers our lowest premium in addition to a health savings account funded by both employers and employees. Employers contribute $200, then match any employee contributions up to $575. Employees can contribute additional funds on a pre-tax basis, up to $3,350 for an individual and $6,750 for a family, to cover out-of-pocket medical and pharmacy costs.
Unused funds are rolled over every year with no limit. Unlike the HRA option, the money in an HSA follows the member even if he or she changes jobs or retires.
|**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.|
|Employee Only||Employee + 1 (Spouse or Child)||Employee + Children||Family|
|Employer Contribution to HSA||$200, plus up to $575 more dollar-for-dollar match of employee contributions|
|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|
*Subject to deductible and applicable co-payment (except maintenance medications)
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.