Blue Cross – Pelican HSA 775


Blue Cross administers the HSA 775 Plan.  Effective July 1, 2011 there is an unlimited
lifetime medical maximum.  The HSA 775 Plan has a $2,000 deductible for employee only
 and $4,000 deductible for all other levels of coverage.  After deductible is met,
the member pays 20% of contracted rate.  The maximum out-of-pocket expense in-network
is $5000 for employee only and $10,000 for all other levels of coverage, including
deductibles.  Note: Individual plan documents should be consulted for more details. See prescription
drug information for the HSA 775 Plan below.  A list of plan providers is available
on Blue Cross’s website: or




The pharmacy benefits for the Pelican HSA Plan are administered by Express Scripts.
All prescriptions, except maintenance drugs, are subject to deductible.  Per 90 day
fill, generic drugs, $10 co-pay, preferred brand drugs, $25 co-pay, non-preferred
brand drugs, $50 co-pay and specialty drugs, $50 co-pay. You can contact Express Scripts
at 800-824-0898.