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Pelican HRA 1000

Administered by Blue Cross Blue Shield

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.

Medical Coverage

  Employee Only Employee + 1 (Spouse or Child) Employee + Children Family
Employer Contribution to HRA $1,000 $2,000 $2,000 $2,000
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

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.

Pelican HRA 1000

Blue Cross Blue Shield Customer Service: 1-800-392-4089



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