Noblesville Schools Medical Plan 108 Section 9: Defined Terms Out-of-Pocket Limit - the maximum amount you pay every year. The Schedule of Benefits will tell you if your plan is subject to an Out-of-Pocket Limit and how the Out-of-Pocket Limit applies. Partial Hospitalization/Day Treatment/High Intensity Outpatient - a structured ambulatory program. The program may be freestanding or Hospital-based and provides services for at least 20 hours per week. Participant - a full-time Participant of the Employer who meets the eligibility requirements specified in the Plan. A Participant must live and/or work in the United States. Pharmaceutical Product(s) - U.S. Food and Drug Administration (FDA)-approved prescription medications or products administered in connection with a Covered Health Care Service by a Physician. Physician - any Doctor of Medicine or Doctor of Osteopathy who is properly licensed and qualified by law. Please Note: Any podiatrist, dentist, psychologist, chiropractor, optometrist, or other provider who acts within the scope of his or her license will be considered on the same basis as a Physician. The fact that the Claims Administrator describes a provider as a Physician does not mean that Benefits for services from that provider are available to you under the Plan. Plan - the Plan Sponsor's Self-Funded group health benefit plan. The "What Is the Summary Plan Description?" provision of the SPD will tell you who the Plan Sponsor of this Plan is. Plan Sponsor - the employer, or other defined or otherwise legally established group, to whom the Plan is issued. The "What Is the Summary Plan Description?" provision of the SPD will tell you who the Plan Sponsor of this Plan is. Pregnancy - includes all of the following: • Prenatal care. • Postnatal care. • Childbirth. • Any complications associated with Pregnancy. Presumptive Drug Test - test to determine the presence or absence of drugs or a drug class in which the results are indicated as negative or positive result. Primary Care Physician - a Physician who has a majority of his or her practice in general pediatrics, internal medicine, obstetrics/gynecology, family practice or general medicine. Private Duty Nursing - nursing care that is provided to a patient on a one-to-one basis by licensed nurses in an inpatient or home setting when any of the following are true: • Services exceed the scope of Intermittent Care in the home. • The service is provided to a Covered Person by an independent nurse who is hired directly by the Covered Person or his/her family. This includes nursing services provided on an inpatient or home- care basis, whether the service is skilled or non-skilled independent nursing. • Skilled nursing resources are available in the facility. • The Skilled Care can be provided by a Home Health Agency on a per visit basis for a specific purpose. Recognized Amount - the amount which Copayment, Coinsurance and applicable deductible, is based on for the below Covered Health Care Services when provided by out-of-Network providers: • Out-of-Network Emergency Health Care Services.