LAC 32:V.303. 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 | $2,500 | No Coverage Retirees prior to March 1, 2015 | $1,000 | No Coverage Individual, Plus One Dependent: Active Employee/Retirees on or after March 1, 2015 | $5,000 | No Coverage Retirees prior to March 1, 2015 | $2,000 | No Coverage Individual, Plus Two or More Dependents: Active Employee/Retirees on or after March 1, 2015 | $7,500 | No Coverage Retirees prior to March 1, 2015 | $3,000 | 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: $500 Prescription: $2,000 | No Coverage Retirees prior to March 1, 2015 | Medical: $0 Prescription: $1000 | No Coverage Individual, Plus One Dependent (Medicare Paying Primary for One): Active Employee/Retirees on or after March 1, 2015 | Medical: $3,000 Prescription: $2,000 | No Coverage Retirees prior to March 1, 2015 | Medical: $1,000 Prescription: $1,000 | No Coverage Individual, Plus One Dependent (Medicare Paying Primary for Two): Active Employee/Retirees on or after March 1, 2015 | Medical: $1,000 Prescription: $2,000 per participant | No Coverage Retirees prior to March 1, 2015 | Medical: $0 Prescription: $1,000 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: $5,500 Prescription: $2,000 | No Coverage Retirees prior to March 1, 2015 | Medical: $2,000 Prescription: $1,000 | No Coverage Individual, Plus Two or More Dependents (Medicare Paying Primary for Two): Active Employee/Retirees on or after March 1, 2015 | Medical: $3,500 Prescription: $2,000 per participant | No Coverage Retirees prior to March 1, 2015 | Medical: $1,000 Prescription: $1,000 per participant | No Coverage Individual, Plus Two or More Dependents (Three with Medicare Paying Primary): Active Employee/Retirees on or after March 1, 2015 | Medical: $1,500 Prescription: $2,000 per participant | No Coverage Retirees prior to March 1, 2015 | Medical: $0 Prescription: $1,000 per participant | 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.