Noblesville Schools Medical Plan 33 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? 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. For Network Benefits, transplantation services must be received from a Designated Provider or Network Provider. The Claims Administrator does not require that cornea transplants be received from a Designated Provider in order for you to receive Network Benefits. Urgent Care Center Services What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. 20% 40% Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Urinary Catheters What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. 20% 40% Does the Amount You Pay Apply to the Out-of-Pocket Limit? Yes Yes Does the Annual Deductible Apply? Yes Yes Virtual Care Services