Noblesville Schools Medical Plan 30 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. Rehabilitation Services - Outpatient Therapy and Manipulative Treatment 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 Limited per year as follows: • 36 visits of cardiac rehabilitation therapy. Scopic Procedures - Outpatient Diagnostic and Therapeutic 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 Skilled Nursing Facility/Inpatient Rehabilitation Facility Services