LAC 32:V.503. 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 Deductibles, Coinsurance Amounts and Copayments) Network | Non-Network Individual | $5,000 | $10,000 Family | $10,000 | $20,000 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 Deductibles, Coinsurance Amounts and Copayments) Network | Non-Network Individual | Medical: $3,000 Prescription: $2,000 | $10,000 Family (Medicare Paying Primary for One) | Medical: $8,000 Prescription: $2,000 | $20,000 Family (Medicare Paying Primary for Two) | Medical: $6,000 Prescription: $2,000 per participant | $20,000 Family (Medicare Paying Primary for Three) | Medical: $4,000 Prescription: $2,000 per participant | $20,000 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.