Noblesville Schools Medical Plan 12 Schedule of Benefits Set 001 Schedule of Benefits Table When Benefit limits apply, the limit refers to any combination of Designated Network Benefits, Network Benefits and Out-of-Network Benefits unless otherwise specifically stated. Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Amounts or, for specific Covered Health Care Services as described in the definition of Recognized Amount in Section 9: Defined Terms. The Allowed Amounts provision near the end of this Schedule of Benefits will tell you when you are responsible for amounts that exceed the Allowed Amount. Covered Health Care Service The Amount You Pay Designated Network and Network The Amount You Pay Out-of-Network What are the Limitations & Exceptions? Ambulance Services Prior Authorization Requirement In most cases, the Claims Administrator will initiate and direct non-Emergency ambulance transportation. For Out-of-Network Benefits, if you are requesting non-Emergency Air Ambulance services (including any affiliated non-Emergency ground ambulance transport in conjunction with non-Emergency Air Ambulance transport), you must obtain prior authorization as soon as possible before transport. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. Emergency Ambulance What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. Ground Ambulance: None Air Ambulance: None Same as Network Does the Amount You Pay Apply to the Out-of-Pocket Limit? Ground Ambulance: Yes Air Ambulance: Yes Same as Network Does the Annual Deductible Apply? Ground Ambulance: Yes Air Ambulance: Yes Same as Network Allowed Amounts for ground and Air Ambulance transport provided by an out-of-Network provider will be determined as described below under Allowed Amounts in this Schedule of Benefits.