Noblesville Schools Medical Plan 34 Schedule of Benefits Set 002 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. 20% Out-of-Network Benefits are not available. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Out-of-Network Benefits are not available. Does the Annual Deductible Apply? Yes Out-of-Network Benefits are not available. Benefits are available only when services are delivered through a Designated Virtual Network Provider. You can find a Designated Virtual Network Provider by contacting the Claims Administrator at www.myuhc.com or the telephone number on your ID card. Wigs What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. 20% 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 Limited to one wig per year. Allowed Amounts Allowed Amounts are the amount the Claims Administrator determines that the Plan will pay for Benefits. • For Designated Network Benefits and Network Benefits for Covered Health Care Services provided by a Network provider, except for your cost sharing obligations, you are not responsible for any difference between Allowed Amounts and the amount the provider bills. • For Out-of-Network Benefits, except as described below, you are responsible for paying, directly to the out-of-Network provider, any difference between the amount the provider bills you and the amount the Claims Administrator will pay for Allowed Amounts. ▪ For Covered Health Care Services that are Ancillary Services received at certain Network facilities on a non-Emergency basis from out-of-Network Physicians, you are not responsible, and the out-of-Network provider may not bill you, for amounts in excess of