Noblesville Schools Medical Plan 34 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 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 Limited to one wig per year. Allowed Amounts Allowed Amounts are the amount the Claims Administrator determines that the Plan will pay for Benefits. • For Designated Network Benefits and Network Benefits for Covered Health Care Services provided by a Network provider, except for your cost sharing obligations, you are not responsible for any difference between Allowed Amounts and the amount the provider bills. • For Out-of-Network Benefits, except as described below, you are responsible for paying, directly to the out-of-Network provider, any difference between the amount the provider bills you and the amount the Claims Administrator will pay for Allowed Amounts. ▪ For Covered Health Care Services that are Ancillary Services received at certain Network facilities on a non-Emergency basis from out-of-Network Physicians, you are not responsible, and the out-of-Network provider may not bill you, for amounts in excess of your Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in the SPD. ▪ For Covered Health Care Services that are non-Ancillary Services received at certain Network facilities on a non-Emergency basis from out-of-Network Physicians who have not satisfied the notice and consent criteria or for unforeseen or urgent medical needs that arise at the time a non-Ancillary Service is provided for which notice and consent has been satisfied as described below, you are not responsible, and the out-of- Network provider may not bill you, for amounts in excess of your Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in the SPD. ▪ For Covered Health Care Services that are Emergency Health Care Services provided by an out-of-Network provider, you are not responsible, and the out-of-Network provider may not bill you, for amounts in excess of your applicable Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in the SPD. ▪ For Covered Health Care Services that are Air Ambulance services provided by an out- of-Network provider, you are not responsible, and the out-of-Network provider may not bill you, for amounts in excess of your applicable Copayment, Coinsurance or deductible which is based on the rates that would apply if the service was provided by a Network provider, which is based on the Recognized Amount as defined in the SPD.