Noblesville Schools Medical Plan 31 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? Prior Authorization Requirement For Out-of-Network Benefits, for a scheduled admission, you must obtain prior authorization five business days before admission, or as soon as is reasonably possible for non-scheduled admissions. 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 admissions or as soon as is reasonably possible for non-scheduled admissions. 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 60 days per year in a Skilled Nursing Facility. 60 days per year in an Inpatient Rehabilitation Facility. Surgery - Outpatient Prior Authorization Requirement For Out-of-Network Benefits, for sleep apnea surgery you must obtain prior authorization five business days before scheduled services are received or, for non-scheduled services, 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. 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 Temporomandibular Joint (TMJ) Services