Noblesville Schools Medical Plan 29 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 30% Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Benefits are limited to a single purchase of each type of prosthetic device every three years. Repair and/or replacement of a prosthetic device would apply to this limit in the same manner as a purchase. Once this limit is reached, Benefits continue to be available for items required by the Women's Health and Cancer Rights Act of 1998. Reconstructive Procedures Prior Authorization Requirement For Out-of-Network Benefits, you must obtain prior authorization five business days before a scheduled reconstructive procedure is performed or, for non-scheduled procedures, within one business day or as soon as is reasonably possible. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts. In addition, for Out-of-Network Benefits you must contact the Claims Administrator 24 hours before admission for scheduled inpatient admissions or as soon as is reasonably possible for non-scheduled inpatient admissions. Depending upon where the Covered Health Care Service is provided, Benefits 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 will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Rehabilitation Services - Outpatient Therapy and Manipulative Treatment What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 30% Limited per year as follows: • 36 visits of cardiac rehabilitation therapy.