La. Admin. Code tit. 32 § V-203
Active Employee/Retirees on or after March 1, 2015 | Retirees prior to March 1, 2015 Without Medicare | |||
Network | Non-Network | Network | Non-Network | |
Individual Only | $3,500 | $4,700 | $2,300 | $4,300 |
Individual Plus One Dependent | $6,000 | $8,500 | $3,600 | $7,600 |
Individual Plus Two or More Dependents | $8,500 | $12,250 | $4,900 | $10,900 |
Out-of-Pocket Maximums1 (Includes All Eligible Copayments, Coinsurance Amounts and Deductibles) | |||||
Active Employee/Retirees on or after March 1, 2015 | Retirees prior to March 1, 2015 Without Medicare | Retirees prior to March 1, 2015 With Medicare | |||
Network | Non-Network | Network | Non-Network | Network and Non-Network | |
Individual Only | Medical: $1,500 Prescription: $2,000 | $4,700 | See Subsection A | See Subsection A | Medical: $1,300 Prescription: $2,000 |
Individual Plus One Dependent (Medicare Paying Primary for One) | Medical: $4,000 Prescription: $2,000 | $8,500 | Medical: $1,600 Prescription: $2,000 | $7,600 | Medical: $3,600 Prescription: $2,000 |
Individual Plus One Dependent (Medicare Paying Primary for Two) | Medical: $2,000 Prescription: $2,000 per participant | $8,500 | Not Applicable | Not Applicable | Medical: $1,600 Prescription: $2,000 per participant |
Individual Plus Two or More Dependents (Medicare Paying Primary for One) | Medical: $6,500 Prescription: $2,000 | $12,250 | Medical: $2,900 Prescription: $2,000 | $10,900 | Medical: $5,900 Prescription: $2,000 |
Individual Plus Two or More Dependents (Medicare Paying Primary for Two) | Medical: $4,500 Prescription: $2,000 per participant | $12,250 | Medical: $900 Prescription: $2,000 per participant | $10,900 | Medical: $3,900 Prescription: $2,000 per participant |
Individual Plus Two or More Dependents (Medicare Paying Primary for Three) | Medical: $2,500 Prescription: $2,000 per participant | $12,250 | Medical: $0 Prescription: $2,000 per participant | $10,900 | Medical: $1,900 Prescription: $2,000 per participant |
1Medical 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, § V-203