Noblesville Schools Medical Plan 10 Schedule of Benefits Set 001 Payment Term And Description Amounts The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network provided under the outpatient prescription drug plan. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. The Out-of-Pocket Limit does not include any of the following and, once the Out-of-Pocket Limit has been reached, you still will be required to pay the following: • Any charges for non-Covered Health Care Services. • The amount you are required to pay if you do not obtain prior authorization as required. • Charges that exceed Allowed Amounts, or the Recognized Amount when applicable. • Copayments or Coinsurance for any Covered Health Care Service shown in the Schedule of Benefits table that does not apply to the Out-of-Pocket Limit. Coupons: The Plan Sponsor may not permit certain coupons or offers from pharmaceutical manufacturers or an affiliate to apply to your Out-of-Pocket Limit. Copayment Copayment is the amount you pay (calculated as a set dollar amount) each time you receive certain Covered Health Care Services. When Copayments apply, the amount is listed on the following pages next to the description for each Covered Health Care Service. Please note that for Covered Health Care Services, you are responsible for paying the lesser of: • The applicable Copayment. • The Allowed Amount, or the Recognized Amount when applicable. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. Coinsurance