Pelican HSA 775

Administered by Blue Cross Blue Shield

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.

Medical Coverage

**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
Deductible (in-network) $2,000 $4,000 $4,000 $4,000
Deductible (out-of-network) $4,000 $8,000 $8,000 $8,000
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
Coinsurance (in-network) 20% 20% 20% 20%
Coinsurance (out-of-network)** 40% 40% 40% 40%

Prescription Coverage


*Subject to deductible and applicable co-payment (except maintenance medications)

Tier Member Responsibility*
Generic $10 co-pay
Preferred $25 co-pay
Non-Preferred $50 co-pay
Specialty $50 co-pay

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.