Octave

Octave Silver Classic Suitcase

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Combined Medical and Drug Deductible	Individual: $6,500.00 Family: $13000 Per Person: $6500
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,000.00 Family: $16000 Per Person: $8000

Primary Doctor	CoPay: $0.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $80.00 CoInsurance: Not Applicable Covered: Covered

Preferred Brand Drugs	CoPay: $240.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Mail Order cost: 48772AR0010006-01- $480 Copay in-network, 48772AR0010006-03- $480 Copay in-network, 48772AR0010006-04- $380 Copay in-network, 48772AR0010006-05- $200 Copay in-network, and 48772AR0010006-06- $70 Copay in-network.
Non Preferred Brand Drugs	CoPay: $1,600.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Mail Order cost: 48772AR0010006-01- $3200 Copay in-network, 48772AR0010006-03- $3200 Copay in-network, 48772AR0010006-04- $3200 Copay in-network, 48772AR0010006-05- $3200 Copay in-network, and 48772AR0010006-06- $900 Copay in-network.
Generic Drugs	CoPay: $35.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Mail Order cost: 48772AR0010006-01- $70 Copay in-network, 48772AR0010006-03- $70 Copay in-network, 48772AR0010006-04- $40 Copay in-network, 48772AR0010006-05- $10 Copay in-network, and 48772AR0010006-06- $10 Copay in-network.
Specialty Drugs	CoPay: $5,000.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Requires Prior Approval from Octave.

Hospital Services	CoPay: $750.00 Copay per Day after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Requires prior notification to Octave.
Inpatient Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Emergency Room	CoPay: $600.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $80.00 CoInsurance: Not Applicable Covered: Covered

Labor and Delivery Hospital Stay

CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Childbirth/delivery professional services: 48772AR0010006-01-40% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 48772AR0010006-02-No charge for in-network and out-of-network services; 48772AR0010006-03-40% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 48772AR0010006-04-40% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 48772AR0010006-05-40% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 48772AR0010006-06-20% 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 the Company.

Pre and Postnatal Office Visit

CoPay: Not Applicable
CoInsurance: 40.00% 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