Noblesville Schools Medical Plan 23 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? Prior Authorization Requirement For Out-of-Network Benefits, for a scheduled admission for Mental Health Care and Substance-Related and Addictive Disorders Services, including an admission for services at a Residential Treatment facility, you must obtain prior authorization five business days before admission or as soon as is reasonably possible for non-scheduled admissions. In addition, for Out-of-Network Benefits you must obtain prior authorization before the following services are received: Partial Hospitalization/Day Treatment/High Intensity Outpatient; Intensive Outpatient Program(s); Intensive Behavioral Therapy, including Applied Behavior Analysis (ABA); psychological testing and transcranial magnetic stimulation. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. Inpatient What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Outpatient What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. Office Visits None All Other Outpatient Services, including Partial Hospitalization/Day Treatment/High Intensity Outpatient/Intensive Outpatient Programs None Intensive Behavioral Therapy None Office Visits 30% All Other Outpatient Services, including Partial Hospitalization/Day Treatment/High Intensity Outpatient/Intensive Outpatient Programs 30% Intensive Behavioral Therapy 30%