Noblesville Schools Medical Plan 24 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? Does the Amount You Pay Apply to the Out-of-Pocket Limit? Office Visits Yes All Other Outpatient Services, including Partial Hospitalization/Day Treatment/High Intensity Outpatient/Intensive Outpatient Programs Yes Intensive Behavioral Therapy Yes Office Visits Yes All Other Outpatient Services, including Partial Hospitalization/Day Treatment/High Intensity Outpatient/Intensive Outpatient Programs Yes Intensive Behavioral Therapy Yes Does the Annual Deductible Apply? Office Visits Yes All Other Outpatient Services, including Partial Hospitalization/Day Treatment/High Intensity Outpatient/Intensive Outpatient Programs Yes Intensive Behavioral Therapy Yes Office Visits Yes All Other Outpatient Services, including Partial Hospitalization/Day Treatment/High Intensity Outpatient/Intensive Outpatient Programs Yes Intensive Behavioral Therapy Yes Virtual Behavioral Health Therapy and Coaching What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. Designated Network AbleTo None Out-of-Network Benefits are not available. Except for the initial consultation, Covered Persons with a high deductible health plan (HDHP) must meet their Annual Deductible before they are able to receive Benefits for these services. There are no deductibles, Copayments or Coinsurance for the initial consultation.