Octave Silver Standardized
Octave
Plan overview
Medical deductible
Individual: $6000
Family: $12000
Per Person: $6000
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $8900
Family: $17800
Per Person: $8900
Office visit
Primary Doctor
CoPay: $40.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Specialist
CoPay: $80.00
CoInsurance: Not Applicable
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: $40.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Mail Order cost: 48772AR0010002-01-$120 Copay in-network; 48772AR0010002-03-$120 Copay in-network; 48772AR0010002-04-$120 Copay in-network; 48772AR0010002-05-$60 Copay in-network; 48772AR0010002-06-$45 Copay in-network
Non preferred brand drugs
CoPay: $80.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Mail Order cost: 48772AR0010002-01-$240 Copay after deductible in-network; 48772AR0010002-03-$240 Copay after deductible in-network; 48772AR0010002-04-$240 Copay after deductible in-network; 48772AR0010002-05-$180 Copay after deductible in-network; 48772AR0010002-06-$150 Copay in-network
Generic drugs
CoPay: $20.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Mail Order cost: 48772AR0010002-01-$60 Copay in-network; 48772AR0010002-03-$60 Copay in-network; 48772AR0010002-04-$60 Copay in-network; 48772AR0010002-05-$30 Copay in-network; 48772AR0010002-06-No Charge in-network
Specialty drugs
CoPay: $350.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Requires Prior Authorization from Octave.
Inpatient coverage
Hospital services
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Inpatient services
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Emergency and urgent care
Emergency room
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Urgent care facility
CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: For childbirth and delivery professional services, the plan's coinsurance after deductible may apply for in network and out of network services. See the plan's Summary of Benefits and Coverage for more cost details on childbirth and delivery professional services. Coverage for Out of Network newborn services is limited to $2000 per Member for all services first 90 days after birth.
Pre and Postnatal office visit
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Coverage for routine ultrasound is limited to 1. Member is encouraged to notify Octave as specified in the Evidence of Coverage.
Vision
Routine Eye Exams for Children
CoPay: No Charge
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 1
Limit Unit: Exam(s) per Year
Major dental care
Routine dental checkups for children
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).