Pelican HSA 775

Administered by Blue Cross Blue Shield of Louisiana and Express Scripts

The Office of Group Benefits offers multiple health plans, including the Pelican HSA 775.The claims administrator is Blue Cross and Blue Shield of Louisiana, while the pharmacy benefit manager is Express Scripts. It features lower premiums than Magnolia plans in exchange for higher deductibles. The Pelican HSA 775 utilizes the Blue Cross and Blue Shield of Louisiana Preferred Care Providers and Blue Cross National Providers Networks. Note that this plan is only available to Active employees. Retirees are not eligible to participate in a Health Savings Account (HSA).

Health Savings Account (HSA)

The Pelican HSA 775 Plan is a high deductible health plan which may be used in conjunction with a HSA for those eligible to participate in such an account. Eligibility to participate in and contribute to a 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 Healthcare Flexible Spending Account (FSA).

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. This $775 total amount counts toward the maximum of the U.S. Internal Revenue Service Annual limits of $3,850 for employee only coverage and $7,750 for family coverage, for the 2023 calendar year - an additional $1,000 if you are age 55 or older.  Employees can contribute additional funds on a pre-tax basis, up to the limits listed above, to cover out-of-pocket medical and pharmacy costs. Unused funds are rolled over every year with no limit. Unlike the Health Reimbursement Arrangement option, the money in an HSA follows the member even if he or she changes jobs or retires.

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. Employees can choose not to contribute to the HSA account; however, in order for LSU to make the $200 contribution, employees will need to submit the HSA Enrollment Form (GB-79) to benefits at benefits@lsu.edu.

Members enrolled in OGB’s HSA 775 are eligible for a personal tax-free health savings account (HSA). HealthEquity, Inc. is Blue Cross Blue Shield’s third party administrator for MySmart$aver HSA banking. The HealthEquity website features other tools to help you understand the benefits of your HSA. To learn more, visit HealthyEquity's webpage. To learn more about how to maximize your HSA, please visit MySmart$aver.  

Medical Coverage

Medical Coverage Employee Only Employee + 1 (Spouse or Child) 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 max (in-network) $5,000 $10,000 $10,000 $10,000
Out-of-pocket max (out-of-network) $10,000 $20,000 $20,000 $20,000

Prescription Coverage

Blue Cross and Blue Shield of Louisiana works in partnership with Express Scripts to administer your prescription formulary drug program for the Pelican HSA 775. Prescriptions are subject to the plan deductible with the exception of maintenance medications.

Tier Member Responsibility*
Generic $10 co-pay
Preferred $25 co-pay
Non-Preferred $50 co-pay
Specialty $50 co-pay

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

Blue Cross Blue Shield of LA



8 a.m. - 5 p.m.
Monday - Friday

Express Scripts


Visit Express Scripts

6 a.m. - 11 p.m.
Seven days a week

HealthEquity, Inc. Account Mentors

Toll free: 1-877-987-8123

Email HealthEquity

24 hours/ 7 days a week



visit OGB

8 a.m. - 4:30 p.m.
Monday - Friday 


Forms & Resources

Health Insurance and Dependents can only be changed during Annual Enrollment or due to a Qualifying Life Event (QLE).

insurance eligibility


benefit job aids and forms

HSA Enrollment Form




2022 Pelican HSA 775 Summary of Benefits

2021 Pelican HSA 775 Schedule of Benefits

2021 Pelican HSA 775 Plan Document