Blue Cross – Pelican HSA 775

Blue Cross - Pelican HSA 775

Medical

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: www.groupbenefits.org or https://www.bcbsla.com/ogb

Pharmacy

Members enrolled in the Pelican HSA have different prescription drug benefits than members enrolled in the other Pelican and Magnolia plans.

There is no separate pharmacy out-of-pocket threshold to meet. Prescription medications are subject to the plan deductible, with the exception of certain maintenance medications.

Prescription Drug Costs

Prescription Tier

Prescription medications are subject to the plan deductible and applicable copay. Certain maintenance medications are not subject to the deductible.

Maintenance & Preventive Medications

Certain maintenance and preventive medications are available without first meeting the Pelican HSA deductible. Members should review the Pelican HSA Maintenance/Preventive Drug List to determine which medications qualify.