Noblesville Schools Medical Plan 28 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? Lab, X-ray or other preventive tests What Is the Copayment or Coinsurance You Pay? This May Include a Copayment, Coinsurance or Both. None 40% 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 40% Does the Amount You Pay Apply to the Out-of-Pocket Limit? No Yes Does the Annual Deductible Apply? No Yes Private Duty Nursing Prior Authorization Requirement For Out-of-Network Benefits, you must obtain prior authorization five business days before receiving services 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.