Noblesville Schools Medical Plan 21 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? 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 Lab, X-Ray and Diagnostic - Outpatient Prior Authorization Requirement For Out-of-Network Benefits, for Genetic Testing, and sleep studies, you must obtain prior authorization five business days before scheduled services are received. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. Lab Testing - Outpatient 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