La. Admin. Code tit. 32 § III-105
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 |
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