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Pelican HSA775

Overview

The Pelican HSA775 plan offers the lowest premiums among our options and includes a separate health savings account (HSA) funded by both employers and employees.

Employer and Employee Contributions

  • Employers contribute $200 to the HSA
  • Employers also match any employee contributions up to an additional $575
  • Employees can contribute to their HSA on a pre-tax basis.

Contribution Limits

  • Individuals can contribute up to $4,400 annually to their HSA to cover out-of-pocket medical and pharmacy costs.
  • Families can contribute up to $8,750 to cover out-of-pocket medical and pharmacy costs.

Annual Enrollment Process

  • A Health Savings Account Enrollment & Payroll Deduction Election/Change Form (GB-79 form) must be filled out each year during Annual Enrollment for the following year’s contributions.

Tax Implications

Medicare Eligibility

  • Active employees who enroll in Medicare are no longer eligible to contribute to a Health Savings Account (HSA).
  • HSA enrollees that are over 65 should stop contributing to their health saving account at least 6 months prior to retirement to avoid IRS tax penalties.

Provider Access

Amount For Employee Only Family
Employer Contribution to HSA $200, plus up to $575 dollar-for-dollar match of employee contributions
Deductible (In-Network) $2,000 $4,000
Deductible (Out-of-Network) $4,000 $8,000
Out-of-pocket max (In-Network) $5,000 $10,000
Out-of-pocket max (Out-of-Network) $10,000 $20,000
Coinsurance (In-Network) 20% 20%
Coinsurance (Out-of-Network) 40% 40%

Pharmacy Benefits

OGB uses a Formulary to help members select the most appropriate, lowest-cost options. The Formulary is reviewed regularly to reassess drug tiers based on the current prescription drug market. Members will continue to pay a portion of the cost of their prescriptions in the form of a copay or coinsurance. The amount members pay toward their prescription depends on whether or not they receive a generic, preferred, non-preferred, or specialty brand drug.

Note: $1,500 threshold does not apply to HSA775.

Note: Maintenance drugs are not subject to your medical deductible.

*Member responsibility is for a prescription drug benefit of up to a 31-day supply. Maintenance medications are not subject to the deductible, but are subject to the pharmacy copay format above.
Tier Member Responsibility*
Generic $10 copay (31-day supply)
Preferred $25 copay (31-day supply)
Non-Preferred $50 copay (31-day supply)
Specialty $50 copay (31-day supply)

*For medications with a 32–62 day supply, the member copay would be 2 times the applicable tier copay.

*For medications with a 63–93 day supply, the member copay would be 3 times the applicable tier copay.

Contact Information

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