La. Admin. Code tit. 32 § III-105

Current through 2024 Legislative Session

Section III-105 - [Effective 1/1/2025] Out of Pocket Maximums

A. Plan Participants When OGB Is the Primary Payer for All Plan Participants

Out-of-Pocket Maximum Per Benefit Period (Includes All Eligible Copayments, Coinsurance Amounts and Deductibles)
	Network	Non-Network
Individual:
Active Employee/Retirees on or after March 1, 2015	$3,500	No Coverage
Retirees prior to March 1, 2015	$2,000	No Coverage
Individual, Plus One Dependent:
Active Employee/Retirees on or after March 1, 2015	$6,000	No Coverage
Retirees prior to March 1, 2015	$3,000	No Coverage
Individual, Plus Two or More Dependents:
Active Employee/Retirees on or after March 1, 2015	$8,500	No Coverage
Retirees prior to March 1, 2015	$4,000	No Coverage

B. Plan Participants When Medicare Is the Primary Payer for at Least One Plan Participant

Out-of-Pocket Maximum1 Per Benefit Period (Includes All Eligible Copayments, Coinsurance Amounts and Deductibles)
	Network	Non-Network
Individual:
Active Employee/Retirees on or after March 1, 2015	Medical: $1,500 Prescription: $2,000	No Coverage
Retirees prior to March 1, 2015	Medical: $500 Prescription: $1,500	No Coverage
Individual, Plus One Dependent (Medicare Paying Primary for One):
Active Employee/Retirees on or after March 1, 2015	Medical: $4,000 Prescription: $2,000	No Coverage
Retirees prior to March 1, 2015	Medical: $1,500 Prescription: $1,500	No Coverage
Individual, Plus One Dependent (Medicare Paying Primary for Two):
Active Employee/Retirees on or after March 1, 2015	Medical: $2,000 Prescription: $2,000 per participant	No Coverage
Retirees prior to March 1, 2015	Medical: $0 Prescription: $1,500 per participant	No Coverage
Individual, Plus Two or More Dependents (Medicare Paying Primary for One):
Active Employee/Retirees on or after March 1, 2015	Medical: $6,500 Prescription: $2,000 per participant	No Coverage
Retirees prior to March 1, 2015	Medical: $2,500 Prescription: $1,500 per participant	No Coverage
Individual, Plus Two or More Dependents (Medicare Paying Primary for Two):
Active Employee/Retirees on or after March 1, 2015	Medical: $4,000 Prescription: $2,000 per participant	No Coverage
Retirees prior to March 1, 2015	Medical: $1,000 Prescription: $1,500 per participant	No Coverage
Individual, Plus Two or More Dependents (Medicare Paying Primary for Three):
Active Employee/Retirees on or after March 1, 2015	Medical: $2,500 Prescription: $2,000 per participant	No Coverage
Retirees prior to March 1, 2015	Medical: $0 Prescription: $1,500	No Coverage

¹ Medical Out-of-Pocket Maximum applies to medical expenditures for all Plan Participants and to Prescription expenditures for Plan Participants when OGB is the primary payer. Prescription Out-of-Pocket Maximum applies to each Plan Participant when Medicare is the primary payer.

La. Admin. Code tit. 32, § III-105

Promulgated by the by the Office of the Governor, Division of Administration, Office of Group Benefits, LR 41:350 (February 2015), effective March 1, 2015, Amended LR 43:2153 (11/1/2017), (effective 1/1/2018), Amended LR 49:1377 (8/1/2023), LR 501467 (10/1/2024), effective 1/1/2025.

AUTHORITY NOTE: Promulgated in accordance with R.S. 42:801(C) and 802(B)(1).