Noblesville Schools Medical Plan 28 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? Lab, X-ray or other preventive tests 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? No Yes Does the Annual Deductible Apply? No Yes Breast pumps 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? No Yes Does the Annual Deductible Apply? No Yes Prosthetic Devices Prior Authorization Requirement For Out-of-Network Benefits, you must obtain prior authorization before obtaining prosthetic devices that exceed $1,000 in cost per device. If you do not obtain prior authorization as required, Benefits will be reduced to 50% of Allowed Amounts.