Noblesville Schools Medical Plan 39 Section 1: Covered Health Care Services Section 1: Covered Health Care Services When Are Benefits Available for Covered Health Care Services? Benefits are available only when all of the following are true: • The health care service, including supplies or Pharmaceutical Products, is only a Covered Health Care Service if it is Medically Necessary. (See definitions of Medically Necessary and Covered Health Care Service in Section 9: Defined Terms.) • You receive Covered Health Care Services while the Plan is in effect. • You receive Covered Health Care Services prior to the date that any of the individual termination conditions listed in Section 4: When Coverage Ends occurs. • The person who receives Covered Health Care Services is a Covered Person and meets all eligibility requirements specified in the Plan. The fact that a Physician or other provider has performed or prescribed a procedure or treatment, or the fact that it may be the only available treatment for a Sickness, Injury, Mental Illness, substance-related and addictive disorders, disease or its symptoms does not mean that the procedure or treatment is a Covered Health Care Service under the Plan. Benefits are provided for services delivered via Telehealth/Telemedicine. Benefits are also provided for Remote Physiologic Monitoring. Benefits for these services are provided to the same extent as an in- person service under any applicable Benefit category in this section unless otherwise specified in the Schedule of Benefits. This section describes Covered Health Care Services for which Benefits are available. Please refer to the attached Schedule of Benefits for details about: • The amount you must pay for these Covered Health Care Services (including any Annual Deductible, Copayment and/or Coinsurance). • Any limit that applies to these Covered Health Care Services (including visit, day and dollar limits on services). • Any limit that applies to the portion of the Allowed Amount or the Recognized Amount when applicable, you are required to pay in a year (Out-of-Pocket Limit). • Any responsibility you have for obtaining prior authorization or notifying the Claims Administrator. Please note that in listing services or examples, when the Plan says "this includes," it is not the Claims Administrator's intent to limit the description to that specific list. When the Plan does intend to limit a list of services or examples, the Plan states specifically that the list "is limited to." Ambulance Services Emergency ambulance transportation by a licensed ambulance service (either ground or Air Ambulance) to the nearest Hospital where the required Emergency Health Care Services can be performed. Non-Emergency ambulance transportation by a licensed ambulance service (either ground or Air Ambulance, as the Claims Administrator determines appropriate) between facilities only when the transport meets one of the following: • From an out-of-Network Hospital to the closest Network Hospital when Covered Health Care Services are required. • To the closest Network Hospital that provides the required Covered Health Care Services that were not available at the original Hospital.