Noblesville Schools Medical Plan 7 Schedule of Benefits Set 001 UnitedHealthcare Choice Plus United Healthcare Services, Inc. Schedule of Benefits How Do You Access Benefits? You can choose to receive Designated Network Benefits, Network Benefits or Out-of-Network Benefits. Designated Network Benefits apply to Covered Health Care Services that are provided by a provider or facility that has been identified as a Designated Provider. Designated Network Benefits are available only for specific Covered Health Care Services as shown in the Schedule of Benefits table below. Network Benefits apply to Covered Health Care Services that are provided by a Network Physician or other Network provider. You are not required to select a Primary Care Physician in order to obtain Network Benefits. Out-of-Network Benefits apply to Covered Health Care Services that are provided by an out-of-Network Physician or other out-of-Network provider, or Covered Health Care Services that are provided at an out- of-Network facility. Emergency Health Care Services provided by an out-of-Network provider will be reimbursed as set forth under Allowed Amounts as described at the end of this Schedule of Benefits. Covered Health Care Services provided at certain Network facilities by an out-of-Network Physician, when not Emergency Health Care Services, will be reimbursed as set forth under Allowed Amounts as described at the end of this Schedule of Benefits. For these Covered Health Care Services, "certain Network facility" is limited to a hospital (as defined in 1861(e) of the Social Security Act), a hospital outpatient department, a critical access hospital (as defined in 1861(mm)(1) of the Social Security Act), an ambulatory surgical center as described in section 1833(i)(1)(A) of the Social Security Act, and any other facility specified by the Secretary. Air Ambulance transport provided by an out-of-Network provider will be reimbursed as set forth under Allowed Amounts as described at the end of this Schedule of Benefits. Ground Ambulance transport provided by an out-of-Network provider will be reimbursed as set forth under Allowed Amounts as described at the end of this Schedule of Benefits. You must show your identification card (ID card) every time you request health care services from a Network provider. If you do not show your ID card, Network providers have no way of knowing that you are enrolled under the Plan. As a result, they may bill you for the entire cost of the services you receive. Additional information about the network of providers and how your Benefits may be affected appears at the end of this Schedule of Benefits. If there is a conflict between this Schedule of Benefits and any summaries provided to you by the Plan Sponsor, this Schedule of Benefits will control. Does Prior Authorization Apply? The Claims Administrator requires prior authorization for certain Covered Health Care Services. Network providers are responsible for obtaining prior authorization before they provide these services to you. Network facilities and Network providers cannot bill you for services they do not prior authorize as required. You can call the Claims Administrator at the telephone number on your ID card.