Noblesville Schools Medical Plan 33 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? Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Urinary Catheters 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 Virtual Care Services What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None Out-of-Network Benefits are not available. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Out-of-Network Benefits are not available. Does the Annual Deductible Apply? Yes Out-of-Network Benefits are not available. Benefits are available only when services are delivered through a Designated Virtual Network Provider. You can find a Designated Virtual Network Provider by contacting the Claims Administrator at www.myuhc.com or the telephone number on your ID card. Wigs