Southeastern will contribute $1,000 to the HRA for employee only coverage, and $2,000
for all other levels of coverage. This employer funded contribution to your HRA can
help offset the deductible you a responsible for. The HRA 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. Effective July 1, 2011 there is an unlimited lifetime medical
maximum. Note: Individual plan documents should be consulted for more details. More information,
including a list of Blue Cross providers is available on Group Benefits website: groupbenefits.org or https://www.bcbsla.com/ogb
Administered by Express Scripts, Inc. (ESI) | Member Drug Questions – 1-866-781-7533Blue Cross and Blue Shield of Louisiana works with Express Scripts, Inc. (ESI) to
administer ourprescription drug program. For ESI’s list of generic, preferred brand, non-preferred
brand, specialty andmaintenance/preventive drugs, go to www.bcbsla.com/ogb.
ESI has a robust pharmacy network that consists of a large group of conveniently located
participatingretail pharmacies as well as an optional mail-service program. You may use any pharmacy
you wish, butthere are advantages to selecting a participating network pharmacy:• Lower costs• No claims to file• No waiting for reimbursement