Octave

Octave Silver AH

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Medical Deductible	Individual: $5,550.00 Family: $11100 Per Person: $5550
Prescription Drug Deductible	Individual: $0.00 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $5,950.00 Family: $11900 Per Person: $5950

Primary Doctor	CoPay: $30.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $45.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered

Preferred Brand Drugs	CoPay: $1,000.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Mail Order cost: 48772AR001003-01- $2000 Copay in-network, 48772AR001003-03- $2000 Copay in-network, 48772AR001003-04- $2000 Copay in-network, 48772AR001003-05- $50 Copay in-network, and 48772AR001003-06- $9.40 Copay in-network.
Non Preferred Brand Drugs	CoPay: $2,000.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Mail Order cost: 48772AR001003-01- $4000 Copay in-network, 48772AR001003-03- $4000 Copay in-network, 48772AR001003-04- $4000 Copay in-network, 48772AR001003-05- $200 Copay in-network, and 48772AR001003-06- $18.80 Copay in-network.
Generic Drugs	CoPay: $100.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Mail Order cost: 48772AR001003-01- $200 Copay in-network, 48772AR001003-03- $200 Copay in-network, 48772AR001003-04- $200 Copay in-network, 48772AR001003-05- $10 Copay in-network, and 48772AR001003-06- $9.40 Copay in-network.
Specialty Drugs	CoPay: $5,950.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Requires Prior Approval from Octave.

Hospital Services	CoPay: $800.00 Copay per Day after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Requires prior notification to Octave.
Inpatient Services	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered

Emergency Room	CoPay: $800.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $45.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered

Labor and Delivery Hospital Stay

CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Childbirth/delivery professional services: 48772AR001003-01-30% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 48772AR001003-02-No charge for in-network and out-of-network services; 48772AR001003-03-30% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 48772AR0010003-04-No charge after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 48772AR0010003-05-No charge after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 48772AR0010003-06-No charge 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: 30.00% 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