Octave

Octave Silver Standardized

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Combined Medical and Drug Deductible	Individual: $5,000.00 Family: $10000 Per Person: $5000
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,000.00 Family: $16000 Per Person: $8000

Primary Doctor	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $80.00 CoInsurance: Not Applicable Covered: Covered

Preferred Brand Drugs	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Mail Order cost: 48772AR0010002-01- $80 Copay in-network, 48772AR0010002-03- $80 Copay in-network, 48772AR0010002-04- $80 Copay in-network, 48772AR0010002-05- $40 Copay in-network, and 48772AR0010002-06- $30 Copay in-network.
Non Preferred Brand Drugs	CoPay: $80.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Mail Order cost: 48772AR0010002-01- $160 Copay after deductible in-network, 48772AR0010002-03- $160 Copay after deductible in-network, 48772AR0010002-04- $160 Copay after deductible in-network, 48772AR0010002-05- $120 Copay after deductible in-network, and 48772AR0010002-06- $100 Copay in-network.
Generic Drugs	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Mail Order cost: 48772AR0010002-01- $40 Copay in-network, 48772AR0010002-03- $40 Copay in-network, 48772AR0010002-04- $40 Copay in-network, and 48772AR0010002-05- $20 Copay in-network
Specialty Drugs	CoPay: $350.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Requires Prior Approval from Octave.

Hospital Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible 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: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $60.00 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: 48772AR0010002-01-40% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 48772AR0010002-02-No charge for in-network and out-of-network services; 48772AR0010002-03-40% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 48772AR0010002-04-40% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 48772AR0010002-05-30% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 48772AR0010002-06-25% Coinsurance 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: 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