Noblesville Schools Medical Plan 15 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? Dental Services - Accident Only 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 Diabetes Services Prior Authorization Requirement For Out-of-Network Benefits, you must obtain prior authorization before obtaining any DME for the management and treatment of diabetes 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. Diabetes Self- Management and Training/Diabetic Eye Exams/Foot Care Depending upon where the Covered Health Care Service is provided, Benefits for diabetes self- management and training/diabetic eye exams/foot care will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Depending upon where the Covered Health Care Service is provided, Benefits for diabetes self- management and training/diabetic eye exams/foot care will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits.