Noblesville Schools Medical Plan 20 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? Yes Yes Does the Annual Deductible Apply? Yes Yes intravenous infusion To receive Network Benefits for the administration of intravenous infusion, you must receive services from a provider the Claims Administrator identifies. Hospice Care Prior Authorization Requirement For Out-of-Network Benefits, you must obtain prior authorization five business days before admission for an Inpatient Stay in a hospice facility or as soon as is reasonably possible. 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 within 24 hours of admission for an Inpatient Stay in a hospice facility. What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None Same as Network Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Same as Network Does the Annual Deductible Apply? Yes Same as Network Hospital - Inpatient Stay Prior Authorization Requirement For Out-of-Network Benefits, for a scheduled admission, you must obtain prior authorization five business days before admission, or as soon as is reasonably possible for non-scheduled admissions. 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.