Noblesville Schools Medical Plan 9 Schedule of Benefits Set 001 When Benefit limits apply, the limit stated refers to any combination of Designated Network Benefits, Network Benefits and Out-of-Network Benefits unless otherwise specifically stated. Benefit limits are calculated on a calendar year basis unless otherwise specifically stated. Payment Term and Description Table Payment Term And Description Amounts The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network Annual Deductible The amount you pay for Covered Health Care Services per year before you are eligible to receive Benefits. The Annual Deductible applies to Covered Health Care Services under the Plan as indicated in this Schedule of Benefits, including Covered Health Care Services provided under the outpatient prescription drug plan. Coupons: The Plan Sponsor may not permit certain coupons or offers from pharmaceutical manufacturers or an affiliate to apply to your Annual Deductible. Amounts paid toward the Annual Deductible for Covered Health Care Services that are subject to a visit or day limit will also be calculated against that maximum Benefit limit. As a result, the limited Benefit will be reduced by the number of days/visits used toward meeting the Annual Deductible. The amount that is applied to the Annual Deductible is calculated on the basis of the Allowed Amount or the Recognized Amount when applicable. The Annual Deductible does not include any amount that exceeds the Allowed Amount. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. $5,000 per Covered Person, not to exceed $10,000 for all Covered Persons in a family. $10,000 per Covered Person not to exceed $20,000 for all Covered Persons in a family. Out-of-Pocket Limit The maximum you pay per year for the Annual Deductible, Copayments or Coinsurance. Once you reach the Out-of- Pocket Limit, Benefits are payable at 100% of Allowed Amounts during the rest of that year. The Out-of-Pocket Limit applies to Covered Health Care Services under the Plan as indicated in this Schedule of Benefits, including Covered Health Care Services $5,000 per Covered Person, not to exceed $10,000 for all Covered Persons in a family. The Out-of-Pocket Limit includes the Annual Deductible. $10,000 per Covered Person, not to exceed $20,000 for all Covered Persons in a family. The Out-of-Pocket Limit includes the Annual Deductible.