La. Admin. Code tit. 32 § V-203

Current through Register Vol. 50, No. 11, November 20, 2024

Section V-203 - [Effective until 1/1/2025] Out of Pocket Maximums

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	$3,500	$4,700	$2,300	$4,300	$3,300
Individual Plus One (Spouse or Child)	$6,000	$8,500	$3,600	$7,600	$5,600
Individual Plus Two	$8,500	$12,250	$4,900	$10,900	$7,900
Individual Plus Three	$8,500	$12,250	$5,900	$13,700	$9,900
Individual Plus Four	$8,500	$12,250	$6,900	$13,700	$11,900
Individual Plus Five	$8,500	$12,250	$7,900	$13,700	$13,700
Individual Plus Six	$8,500	$12,250	$8,900	$13,700	$13,700
Individual Plus Seven	$8,500	$12,250	$9,900	$13,700	$13,700
Individual Plus Eight	$8,500	$12,250	$10,900	$13,700	$13,700
Individual Plus Nine	$8,500	$12,250	$11,900	$13,700	$13,700
Individual Plus Ten	$8,500	$12,250	$12,900	$13,700	$13,700
Individual Plus Eleven or More	$8,500	$12,250	$13,700	$13,700	$13,700

La. Admin. Code tit. 32, § V-203

Promulgated by the Office of the Governor, Division of Administration, Office of Group Benefits, LR 41:355 (February 2015), effective March 1, 2015, Amended LR 43:2155 (11/1/2017), (effective 1/1/2018).

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