Office Of Group Benefits - Enrollment Change Form
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1
2STATE OF LOUISIANA - OFFICE OF GROUP BENEFITS - ENROLLMENT/CHANGE FORM
(PAGE 1 of 2)
AGENCY NUMBER
AGENCY NAME
PRIMARY PLAN PARTICIPANT / EMPLOYEE NAME
DATE OF HIRE
Section 1 – Primary Plan Participant / Employee Information
NAME (LAST, FIRST, MIDDLE INITIAL)
NAME CHANGE
SOCIAL SECURITY NUMBER
DATE OFBIRTH
Y N
PHYSICAL ADDRESS
CITY
STATE
ZIP CODE
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP CODE
HOME PHONE NUMBER
WORK / ALT PHONE NUMBER
EMAIL ADDRESS
SEX
(
)
(
)
M F
Section 2 – Enrollment Information
LEVEL OF HEALTH AND LIFE COVERAGE – FOR PLAN SELECTION SEE SECTIONS THREE AND FOUR.
(If adding more than 4 dependents, employee must complete, sign and submit a second GB-01 form)
Employee Only
Employee + Child(ren)
Employee + Spouse
Family
NAME
RELATIONSHIP
SEX
BIRTH DATE
ADD/
SOCIAL SECURITY NUMBER
HEALTH
DEP.
(LAST, FIRST, MIDDLE INITIAL)
(MM/DD/YYYY)
DELETE
LIFE
SPOUSE
M
ADD
YES
YES
F
DELETE
DEPENDENT
M
ADD
YES
YES
F
DELETE
DEPENDENT
M
ADD
YES
YES
F
DELETE
DEPENDENT
M
ADD
YES
YES
F
DELETE
DEPENDENT
M
ADD
YES
YES
F
DELETE
Section 3 – Health Plan Selection
COMPLETE THE APPLICABLE SECTION BELOW. SELECT ONLY ONE HEALTH PLAN.
Active Employees and Non-Medicare Retirees
Pelican HRA 1000 (Administered by Blue Cross)
Magnolia Local (Limited Provider Network - Administered by Blue Cross)
Magnolia Local Plus (Administered by Blue Cross)
Vantage Medical Home HMO (MHHP) (Insured by Vantage Health Plan)(HMO-POS)
Magnolia Open Access (Administered by Blue Cross)
LSU First Option 1 (for Eligible LSU Active/Non-Medicare Retirees only)
LSU First Option 2 (for Eligible LSU Active/Non-Medicare Retirees only)
Pelican HSA 775 (Actives Only -Administered by Blue Cross)
$___________ HSA monthly deduction
Medicare Retirees
OGB Secondary Plans:
Pelican HRA 1000 (Administered by Blue Cross)
Magnolia Local (Limited Provider Network - Administered by Blue Cross)
Magnolia Local Plus (Administered by Blue Cross)
Vantage Medical Home HMO (MHHP) (Insured by Vantage Health Plan)(HMO-POS)
LSU First Option 1 (for Eligible LSU retirees only)
Magnolia Open Access (Administered by Blue Cross)
LSU First Option 2 (for Eligible LSU retirees only)
Optional: Retiree 100
Employee Only Dependent Only Employee + 1 Dependent
OGB Sponsored Medicare Advantage Plans:
MEDICARE VERIFICATION
Retiree and all covered dependents must have both Medicare A and Medicare B
EMPLOYEE
SPOUSE
Vantage Medicare Advantage Premium HMO-POS Plan
Vantage Medicare Advantage HMO-POS Plan
No Coverage
No Coverage
Vantage Medicare Advantage Zero Premium Plan
Hospital (Part A)
Hospital (Part A)
Peoples Health Medicare Advantage Plan
Medical (Part B)
Medical (Part B)
One Exchange (Enrollment is conducted through One Exchange.
Drugs (Part D)
Drugs (Part D)
(Please call 1-855-663-4228 or visit to enroll)
A COPY OF MEDICARE CARD MUST BE ATTACHED
Agency – Continue completing form on page 2
GB-01
REV 01-16
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