PELICAN HSA775

OGB offers the Pelican HSA775 option to active employees. This plan is administered by Blue Cross and Blue Shield of Louisiana and features lower premiums compared to Magnolia plans in exchange for higher deductibles.

Health Savings Account

One of the benefits of choosing the Pelican HSA775 is the option to enroll in a health savings account (HSA). The HSA allows you to use pre-tax dollars to pay eligible medical and pharmacy expenses for you and your eligible dependents until you satisfy your deductible. It can also help you save for future health care expenses.

Your employer will contribute $200 per plan year to help jump-start your savings and will match your tax-free contributions made through payroll deduction dollar-for-dollar, up to an additional $575 per plan year. For the 2016 calendar year, the U.S. Internal Revenue Service limits total tax-free contributions to $3,400 for employee coverage and $6,750 for family coverage – plus an additional $1,000 if you are age 55 or older.

How does it work? – Members will be issued a debit card that can be used to cover eligible medical expenses, such as coinsurance, co-pays, deductibles, and services as well as pharmacy, dental, and vision expenses.

Members enrolled in OGB’s HSA775 are eligible for a personal tax-free health savings account (HSA). HealthEquity, Inc. is Blue Cross Blue Shield’s third party administrator for MySmart$aver HSA banking.

The HealthEquity website features other tools to help you understand the benefits of your HSA. Click here to learn more.

Click here to learn how to maximize your HSA.

The Pelican HSA775 Plan is a high deductible health plan which may be used in conjunction with an HSA for those eligible to participate in such an account. Eligibility to participate in and contribute to an HSA must be met on a monthly basis. It is your responsibility to ensure that you are eligible to maintain an HSA. The below factors affect your eligibility to participate in and/or make contributions to an HSA:

  • Neither you nor your spouse may be covered by Medicare at any time during the Plan year (Medicare Part A coverage begins six months back from the date one applies for Medicare, social security, or railroad retiree benefits, but no earlier than the first month one was eligible for Medicare. Therefore, the general advisory is that you stop contributing to your health savings account at least six months before you apply for any of those benefits.)
  • You must not be covered by any other health plan that is not a high-deductible health plan.
  • You may not be covered by Veteran’s services during the last three months.
  • You may not be active-duty military with Tricare coverage.
  • You may not be claimed as a dependent on another person’s tax return.
  • Neither you nor your spouse may be participating in a General-Purpose Flexible Spending Account (“FSA”) (Limited-Purpose FSAs are allowed).

MEDICAL COVERAGE

 

Single

Employee
+ Spouse

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

Coinsurance (In-Network)

20%

20%

20%

20%

Coinsurance (Out-of-Network)

40%

40%

40%

40%

Out-of-Pocket Maximum (In-Network)

$5,000

$10,000

$10,000

$10,000

Out-of-Pocket Maximum (Out-of-Network)

$10,000

$20,000

$20,000

$20,000

 

PHARMACY BENEFITS – EXPRESS SCRIPTS

Blue Cross and Blue Shield of Louisiana works in partnership with Express Scripts® to administer your prescription formulary drug program for the Pelican HSA775. Prescriptions are subject to the plan deductible with the exception of maintenance medications.

Tier

Member Co-Pay*

Generic

$10

Preferred

$25

Non-Preferred

$50

Specialty

$50

*Subject to deductible and applicable co-payment. Maintenance drugs are not subject to the deductible.

Click on the links below for more information on the pharmacy benefits through Express Scripts.

Express Scripts 2015 Maintenance/Preventative Drug List

Blue Selections – Rx Member Guide

 

CONTACT INFORMATION

Blue Cross and Blue Shield of LA

www.bcbsla.com/ogb

1-800-392-4089

8:00 AM – 5:00 PM CT Monday-Friday

Express Scripts

www.express-scripts.com/index.html

1-866-781-7533

6:00 AM – 11:00 PM CT

Seven Days a Week

HealthEquity, Inc. Account Mentors

memberservices@healthequity.com

Toll-free: 1-877-987-8123

24 hours/ 7 Days a Week

Provider Directory

2017 Schedule of Benefits

2017 Benefit Plan

Medicare Eligibility and your HSA

Benefit Comparison

Premium Rates

HRA vs HSA