1. 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

2. 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.

Authority Note

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

Historical Note

HISTORICAL NOTE: Promulgated by the Office of the Governor, Division of Administration, Office of Group Benefits, LR 41:359 (February 2015), effective March 1, 2015, amended LR 50:1469 (October 2024), effective January 1, 2025.