Noblesville Schools Medical Plan 16 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? Diabetes Self- Management Items For diabetes equipment, Benefits will be the same as those stated under Durable Medical Equipment (DME), Orthotics and Supplies. For diabetes supplies, you pay none of the Allowed Amount and the Annual Deductible applies. For diabetes equipment, Benefits will be the same as those stated under Durable Medical Equipment (DME), Orthotics and Supplies. For diabetes supplies, you pay 30% of the Allowed Amount and the Annual Deductible applies. Coinsurance applies to the Out-of- Pocket Limit. Benefits for diabetes equipment that meets the definition of DME are subject to the limit stated under Durable Medical Equipment (DME), Orthotics and Supplies. Durable Medical Equipment (DME), Orthotics and Supplies Prior Authorization Requirement For Out-of-Network Benefits, you must obtain prior authorization before obtaining any DME or orthotic that costs more than $1,000 (either retail purchase cost or cumulative retail rental cost of a single item). If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. 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 Shoe inserts, arch supports, shoe orthotics and shoes (standard or custom), lifts and wedges limited to one pair or one shoe, as needed, per year. To receive Network Benefits, you must obtain the DME or orthotic from the vendor the Claims Administrator identifies or from the prescribing Network Physician. Emergency Health Care Services - Outpatient What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None Same as Network Note: If you are confined in an out-of-Network Hospital after you receive outpatient Emergency Health Care Services, you must notify the Claims Administrator within one business day or on the same day of