Noblesville Schools Medical Plan 22 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? X-Ray and Other Diagnostic 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 Major Diagnostic and Imaging - 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 Mental Health Care and Substance-Related and Addictive Disorders Services