Octave

Octave Gold Standardized

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Combined Medical and Drug Deductible	Individual: $1,500.00 Family: $3000 Per Person: $1500
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,800.00 Family: $15600 Per Person: $7800

Primary Doctor	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Preferred Brand Drugs	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Mail Order cost: 48772AR001001-01- $60 Copay in-network, and 48772AR001001-03- $60 Copay in-network
Non Preferred Brand Drugs	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Mail Order cost: 48772AR001001-01- $120 Copay in-network, and 48772AR001001-03- $120 Copay in-network
Generic Drugs	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Mail Order cost: 48772AR001001-01- $30 Copay in-network, and 48772AR001001-03- $30 Copay in-network
Specialty Drugs	CoPay: $250.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Requires Prior Approval from Octave.

Hospital Services	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Requires prior notification to Octave.
Inpatient Services	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered

Emergency Room	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $45.00 CoInsurance: Not Applicable Covered: Covered

Labor and Delivery Hospital Stay

CoPay: Not Applicable
CoInsurance: 25.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Childbirth/delivery professional services: 48772AR0010001-01-25% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 48772AR0010001-02-No charge for in-network and out-of-network services; 48772AR0010001-03-25% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; Coverage for Out of Network newborn services is limited to $2000 per person for all services first 90 days after birth. Coverage requires Prior Notification to Octave.

Pre and Postnatal Office Visit

CoPay: Not Applicable
CoInsurance: 25.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Requires Prior Notification to Octave. Coverage for routine ultrasound is limited to 1.

Routine Eye Exams for Children

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered