Noblesville Schools Medical Plan 13 Schedule of Benefits Set 001 Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? Non-Emergency Ambulance What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. Ground Ambulance: None Air Ambulance: None Ground Ambulance: Same as Network Air Ambulance: Same as Network Does the Amount You Pay Apply to the Out-of-Pocket Limit? Ground Ambulance: Yes Air Ambulance: Yes Ground Ambulance: Same as Network Air Ambulance: Same as Network Does the Annual Deductible Apply? Ground Ambulance: Yes Air Ambulance: Yes Ground Ambulance: Same as Network Air Ambulance: Same as Network Ground or Air Ambulance, as the Claims Administrator determines appropriate. Allowed Amounts for ground and Air Ambulance transport provided by an out-of-Network provider will be determined as described below under Allowed Amounts in this Schedule of Benefits. Cellular and Gene Therapy Prior Authorization Requirement For Out-of-Network Benefits, you must obtain prior authorization as soon as the possibility of a Cellular or Gene Therapy arises. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. In addition, for Out-of-Network Benefits, you must contact the Claims Administrator 24 hours before admission for scheduled admissions or as soon as is reasonably possible for non-scheduled admissions. Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. For Network Benefits, Cellular or Gene Therapy services must be received from a Designated Provider. Chronic Pain Management