Common use of Leave for Relatives of Military Personnel Clause in Contracts

Leave for Relatives of Military Personnel. It is the responsibility of the employee, upon his/her return to school, to fill out an absence report. Benefit Period January 1st through December 31st Dependent Age Limit 26 Removal upon End of Month Blood Pint Deductible 0 pints Overall Annual Benefit Period Maximum Unlimited Wellness Plan Deductible – Single/Family1 $500/$1,000 $500/$1,000 High Deductible Health Plan – Single/Family1 $750/$1,500 $750/$1,500 Requirements for Wellness Plan (Deductible changes occurs on calendar year basis) Complete Screening and/or Physician form and Health Assessment – November 1st. Complete Screening and/or Physician form and Health Assessment – November 1st. Coinsurance 90% 70% Coinsurance Out-of-Pocket Maximum (Excluding Deductible) – Single/Family $1,000/$2,000 (Wellness) $750/$1,500 (HDHP) $2,500/$5,000 (Wellness) $2,250/$4,500 (HDHP) Coinsurance Out-of-Pocket Maximum (Including Deductible) – Single/Family $1,500/$3,000 (Wellness) $1,500/$3,000 (HDHP) $3,000/$6,000 (Wellness) $3,000/$6,000 (HDHP) Office Visit (Illness/Injury)2 $25 copay, then 100% $25 copay, then 70% Specialist Office Visit2 $40 copay, then 100% $40 copay, then 70% Urgent Care Office Visit2 $40 copay, then 100% $40 copay, then 70% Preventive Services in accordance with federal law6 100% 70% after deductible Routine Physical Exams 2 100% $25 copay, then 70% Well Child Care Services including Exam, Routine Vision, Routine Hearing Exams, Well Child Care Immunizations and Laboratory Tests (Birth to age 21, Unlimited) 100% $25 copay, then 70% Routine Mammogram (One per benefit period) 100% 70% not subject to deductible Routine Pap Test (One per benefit period) 100% 70% not subject to deductible Routine Prostate Specific Antigen (PSA) 100% 70% not subject to deductible Routine Endoscopies 100% 70% not subject to deductible All Routine X-rays, Medical Tests and Laboratory Tests 100% 70% not subject to deductible Surgical Services 90% after deductible 70% after deductible Diagnostic Services 90% after deductible 70% after deductible Physical & Occupational Therapy – Facility and Professional (40 visits combined per benefit period) 90% after deductible 70% after deductible Chiropractic Therapy – Professional Only (12 visits per benefit period) 50% after deductible 50% after deductible Speech Therapy – Facility and Professional (20 visits per benefit period) 90% after deductible 70% after deductible Cardiac Rehabilitation 90% after deductible 70% after deductible Emergency use of an Emergency Room3 $100 copay, then 100% Non-Emergency use of an Emergency Room4 $200 copay, then 90% $200 copay, then 70% Semi-Private Room and Board – Including Ancillaries (365 days per in-hospital benefit period)5 90% after deductible 70% after deductible Maternity 90% after deductible 70% after deductible Skilled Nursing Facility (Two days available for each unused in-hospital day) 90% after deductible 70% after deductible Human Organ Transplants 90% after deductible 70% after deductible Allergy Testing and Treatments 90% after deductible 70% after deductible Ambulance – air if medically necessary 90% after deductible 70% after deductible Durable Medical Equipment 90% after deductible 70% after deductible Home Healthcare 90% after deductible 70% after deductible Hospice Services 90% after deductible 70% after deductible Private Duty Nursing 90% after deductible 70% after deductible Inpatient Mental Health and Substance Abuse Services Benefits paid are based on corresponding medical benefits Outpatient Mental Health and Substance Abuse Services Note: Services requiring a copayment are not subject to the single/family deductible. Deductible and coinsurance expenses incurred for services by a non-network provider will also apply to the network deductible and coinsurance out-of-pocket limits. Deductible and coinsurance expenses incurred for services by a network provider will also apply to the non-network deductible and coinsurance out-of-pocket limits. Non-Contracting and Facility Other Providers will pay the same as Non-Network. Benefits will be determined based on Medical Mutual’s medical and administrative policies and procedures. This document is only a partial listing of benefits. This is not a contract of insurance. No person other than an officer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or certificate will contain the complete listing of covered services. In certain instances, Medical Mutual’s payment may not equal the percentage listed above. However, the covered person’s coinsurance will always be based on the lesser of the provider’s billed charges or Medical Mutual’s negotiated rate with the provider. 1Maximum family deductible. Member deductible is the same as single deductible. 4th quarter carryover applies. 2The office visit copay applies to the cost of the office visit only. 3Copay waived if admitted. The copay applies to room charges only. All other covered charges are not subject to deductible. 4Copay waived if admitted. The copay applies to room charges only. All other covered charges are subject to deductible and coinsurance. 5An in-hospital benefit period is a period of time beginning when the member enters a hospital and ending when he/she has been out for 90 consecutive days. 6Preventive services include evidence-based services that have a rating of “A” or “B” in the United States Preventive Services Task Force, routine immunizations and other screenings, as provided for in the Patient Protection and Affordable Care Act. Wellness Ideal Plan – Non-Grandfathered Benefit Period January 1st through December 31st Dependent Age Limit 26 / Removal upon End of Month Proton Pump Inhibitors (i.e., Prilosec OTC – Omeprazole)1 $0 30 Retail Program3 Immunization and Generic Contraceptives2 $0 N/A Generic Copayment $7.50 30 Formulary Copayment $25 30 Non-Formulary Copayment $50 30 Home Delivery Program3 Generic Copayment $15 90 Formulary Copayment $50 90 Non-Formulary Copayment $100 90 Note: Benefits will be determined based on Medical Mutual’s medical and administrative policies and procedures. This document is only a partial listing of benefits. This is not a contract of insurance. No person other than an officer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or certificate will contain the complete listing of covered services. • Diabetic Supplies o Retail: only needles/syringes are covered o Home Delivery/Mail Order: all diabetic supplies are covered, including needles/syringes, blood/urine test strips, lancets, alcohol swabs/wipes • Coverage Management Programs included – Prior Approval, Step Therapy and Quantity Duration 1Proton Pump Inhibitors (PPI’s) are a class of drugs that inhibit gastric acid production and are used to treat a variety of gastrointestinal conditions. 2Coverage includes Preventive Medications, in accordance with Federal Law. 3If your Prescription Order is for a Prescription Drug that is available through the Home Delivery Prescription Drug program and you choose not to use the Home Delivery Prescription Drug program, no benefit will be provided when your Prescription Order is filled beyond the third fill. NAME DATE POSITION SCHOOL Competency A: Demonstrates the ability to plan and deliver guidance services. S U Comments: Competency B: Demonstrates knowledge of counseling techniques and student development. S U Comments: Competency C: Demonstrates the ability to utilize group management techniques. S U Comments: Competency D: Shows sensitivity to student needs by maintaining a positive school climate. S U Competency E: Demonstrates ability to assess student/program needs for academic support. S U Comments: Competency F: Demonstrates ability to communicate effectively with parents, students, teachers, and administrators. S U Comments: Competency G: Demonstrates willingness to assume general professional responsibilities. S U Comments: Competency H: Demonstrates a commitment to professional growth. S U Comments: Competency I: Shows evidence of professional characteristics. S U Comments: OVERALL EVALUATION: S U Not accepted. My signature evidences receipt of this document only. I have read this document and understand the contents. School Counselor’s Signature / Date Counselor (name) School (name) Observer Date Beg. Time End Time Directions: This instrument is to be used for the minimum observation period of thirty minutes. Place a check by the indicator number when the behavior is observed. Place an “X” observed, but outside of observation time frame. Use the Comments/Recommendations space for descriptive notes.

Leave for Relatives of Military Personnel. It is the responsibility of the employee, upon his/her return to school, to fill out an absence report. Superintendent’s Signature Date Benefit Period January 1st through December 31st Dependent Age Limit 19 Dependent / 25 Student Removal upon End of Month Blood Pint Deductible 0 pints Lifetime Maximum $2,000,000 Benefit Period Deductible – Single/Family1 $500/$1,000 $500/$1,000 Coinsurance 90% 80% Coinsurance Maximum – Single/Family1 $500/$1,000 $1,000/$2,000 Coinsurance Out-of-Pocket Maximum (Including Deductible) – Single/Family $1,000/$2,000 $1,500/$3,000 Office Visit (Illness/Injury)2 $20 copay, then 100% $20 copay, then 80% Urgent Care Office Visit2 $20 copay, then 100% $20 copay, then 80% Routine Physical Exams (Ages nine and over)2 $20 copay, then 100% $20 copay, then 80% Well Child Care Services including Exam, Immunizations and Laboratory Tests (Birth to age nine, limited to a $500 maximum per benefit period)2 Exam - $20 copay, then 100% Immunizations/Labs – 90% - Not subject to deductible $20 copay, then 80% Immunizations/Labs – 80% - Not subject to deductible Routine Mammogram (One per benefit period) 90% not subject to deductible 80% not subject to deductible Routine Pap Test (One per benefit period) 90% not subject to deductible 80% not subject to deductible Routine Prostate Specific Antigen (PSA) 90% not subject to deductible 80% not subject to deductible Routine Endoscopies 90% not subject to deductible 80% not subject to deductible All Routine X-rays, Medical Tests and Laboratory Tests (Ages nine and over) 90% not subject to deductible 80% not subject to deductible Surgical Services 90% after deductible 80% after deductible Diagnostic Services 90% after deductible 80% after deductible Physical & Occupational Therapy – Facility and Professional (40 visits combined per benefit period) 90% after deductible 80% after deductible Chiropractic Therapy – Professional Only (12 visits per benefit period) 50% after deductible 50% after deductible Speech Therapy – Facility and Professional (20 visits per benefit period) 90% after deductible 80% after deductible Cardiac Rehabilitation 90% after deductible 80% after deductible Emergency use of an Emergency Room3 75% copay, then 100% Non-Emergency use of an Emergency Room4 $75 copay, then 90% $75 copay, then 80% Semi-Private Room and Board – Including Ancillaries (365 days per in-hospital benefit period)5 90% after deductible 80% after deductible Maternity 90% after deductible 80% after deductible Skilled Nursing Facility (Two days available for each unused in-hospital day) 90% after deductible 80% after deductible Human Organ Transplants 90% after deductible 80% after deductible Allergy Testing and Treatments 90% after deductible 80% after deductible Ambulance – air if medically necessary 90% after deductible 80% after deductible Durable Medical Equipment 90% after deductible 80% after deductible Home Healthcare 90% after deductible 80% after deductible Hospice Services 90% after deductible 80% after deductible Private Duty Nursing 90% after deductible 80% after deductible Inpatient Mental Health and Substance Abuse Services (31 days per benefit period; Substance Abuse limited to 3 admissions per Lifetime) 90% after deductible 80% after deductible Outpatient Mental Health and Substance Abuse Services (50 visits per benefit period) 50% after deductible 50% after deductible Note: Services requiring a copayment are not subject to the single/family deductible. Deductible and coinsurance expenses incurred for services by a non-network provider will also apply to the network deductible and coinsurance out-of-pocket limits. Deductible and coinsurance expenses incurred for services by a network provider will also apply to the non-network deductible and coinsurance out-of-pocket limits. Non-Contracting and Facility Other Providers will pay the same as Non-Network. Benefits will be determined based on Medical Mutual’s medical and administrative policies and procedures. This document is only a partial listing of benefits. This is not a contract of insurance. No person other than an officer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or certificate will contain the complete listing of covered services. In certain instances, Medical Mutual’s payment may not equal the percentage listed above. However, the covered person’s coinsurance will always be based on the lesser of the provider’s billed charges or Medical Mutual’s negotiated rate with the provider. 1Maximum family deductible. Member deductible is the same as single deductible. 4th quarter carryover applies. 2The office visit copay applies to the cost of the office visit only. 3Copay waived if admitted. The copay applies to room charges only. All other covered charges are not subject to deductible. 4Copay waived if admitted. The copay applies to room charges only. All other covered charges are subject to deductible and coinsurance. 5An in-hospital benefit period is a period of time beginning when the member enters a hospital and ending when he/she has been out for 90 consecutive days. Benefit Period January 1st through December 31st Dependent Age Limit Same as Medical Generic Copayment $10 30 Brand Name Copayment $25 30 Generic Copayment $20 90 Brand Name Copayment $50 90 Note: Benefits will be determined based on Medical Mutual’s medical and administrative policies and procedures. This document is only a partial listing of benefits. This is not a contract of insurance. No person other than an officer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or certificate will contain the complete listing of covered services. • Oral Contraceptives are covered • Diabetic Supplies o Retail: only needles/syringes are covered o Home Delivery/Mail Order: all diabetic supplies are covered, including needles/syringes, blood/urine test strips, lancets, alcohol swabs/wipes Benefit Period January 1st through December 31st Dependent Age Limit 26 Removal upon End of Month Blood Pint Deductible 0 pints Overall Annual Benefit Period Maximum Unlimited Wellness Plan Deductible – Single/Family1 $500/$1,000 $500/$1,000 High Deductible Health Plan – Single/Family1 $750/$1,500 $750/$1,500 Requirements for Wellness Plan (Deductible changes occurs on calendar year basis) Complete Screening and/or Physician form and Health Assessment – November 1st. Complete Screening and/or Physician form and Health Assessment – November 1st. Coinsurance 90% 70% Coinsurance Out-of-Pocket Maximum (Excluding Deductible) – Single/Family $1,000/$2,000 (Wellness) $750/$1,500 (HDHP) $2,500/$5,000 (Wellness) $2,250/$4,500 (HDHP) Coinsurance Out-of-Pocket Maximum (Including Deductible) – Single/Family $1,500/$3,000 (Wellness) $1,500/$3,000 (HDHP) $3,000/$6,000 (Wellness) $3,000/$6,000 (HDHP) Office Visit (Illness/Injury)2 $25 copay, then 100% $25 copay, then 70% Specialist Office Visit2 $40 copay, then 100% $40 copay, then 70% Urgent Care Office Visit2 $40 copay, then 100% $40 copay, then 70% Preventive Services in accordance with federal law6 100% 70% after deductible Routine Physical Exams 2 100% $25 copay, then 70% Well Child Care Services including Exam, Routine Vision, Routine Hearing Exams, Well Child Care Immunizations and Laboratory Tests (Birth to age 21, Unlimited) 100% $25 copay, then 70% Routine Mammogram (One per benefit period) 100% 70% not subject to deductible Routine Pap Test (One per benefit period) 100% 70% not subject to deductible Routine Prostate Specific Antigen (PSA) 100% 70% not subject to deductible Routine Endoscopies 100% 70% not subject to deductible All Routine X-rays, Medical Tests and Laboratory Tests 100% 70% not subject to deductible Surgical Services 90% after deductible 70% after deductible Diagnostic Services 90% after deductible 70% after deductible Physical & Occupational Therapy – Facility and Professional (40 visits combined per benefit period) 90% after deductible 70% after deductible Chiropractic Therapy – Professional Only (12 visits per benefit period) 50% after deductible 50% after deductible Speech Therapy – Facility and Professional (20 visits per benefit period) 90% after deductible 70% after deductible Cardiac Rehabilitation 90% after deductible 70% after deductible Emergency use of an Emergency Room3 $100 copay, then 100% Non-Emergency use of an Emergency Room4 $200 copay, then 90% $200 copay, then 70% Semi-Private Room and Board – Including Ancillaries (365 days per in-hospital benefit period)5 90% after deductible 70% after deductible Maternity 90% after deductible 70% after deductible Skilled Nursing Facility (Two days available for each unused in-hospital day) 90% after deductible 70% after deductible Human Organ Transplants 90% after deductible 70% after deductible Allergy Testing and Treatments 90% after deductible 70% after deductible Ambulance – air if medically necessary 90% after deductible 70% after deductible Durable Medical Equipment 90% after deductible 70% after deductible Home Healthcare 90% after deductible 70% after deductible Hospice Services 90% after deductible 70% after deductible Private Duty Nursing 90% after deductible 70% after deductible Inpatient Mental Health and Substance Abuse Services Benefits paid are based on corresponding medical benefits Outpatient Mental Health and Substance Abuse Services Note: Services requiring a copayment are not subject to the single/family deductible. Deductible and coinsurance expenses incurred for services by a non-network provider will also apply to the network deductible and deductibleand coinsurance out-of-pocket limits. Deductible and coinsurance expenses incurred for services by a network provider will also apply to the non-network deductible and coinsurance out-of-pocket limits. Non-Contracting and Facility Other Providers will pay the same as Non-Network. Benefits will be determined based on Medical Mutual’s medical and administrative policies and procedures. This document is only a partial listing of benefits. This is not a contract of insurance. No person other than an officer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or certificate will contain the complete listing of covered services. In certain instances, Medical Mutual’s payment may not equal the percentage listed above. However, the covered person’s coinsurance will always be based on the lesser of the provider’s billed charges or Medical Mutual’s negotiated rate with the provider. 1Maximum family deductible. Member deductible is the same as single deductible. 4th quarter carryover applies. 2The office visit copay applies to the cost of the office visit only. 3Copay waived if admitted. The copay applies to room charges only. All other covered charges are not subject to deductible. 4Copay waived if admitted. The copay applies to room charges only. All other covered charges are subject to deductible and coinsurance. 5An in-hospital benefit period is a period of time beginning when the member enters a hospital and ending when he/she has been out for 90 consecutive days. 6Preventive services include evidence-based services that have a rating of “A” or “B” in the United States Preventive Services Task Force, routine immunizations and other screenings, as provided for in the Patient Protection and Affordable Care Act. Wellness Ideal Plan – Non-Grandfathered Benefit Period January 1st through December 31st Dependent Age Limit 26 / Removal upon End of Month Proton Pump Inhibitors (i.e., Prilosec OTC – Omeprazole)1 $0 30 Retail Program3 Immunization and Generic Contraceptives2 $0 N/A Generic Copayment $7.50 30 Formulary Copayment $25 30 Non-Formulary Copayment $50 30 Home Delivery Program3 Generic Copayment $15 90 Formulary Copayment $50 90 Non-Formulary Copayment $100 90 Note: Benefits will be determined based on Medical Mutual’s medical and administrative policies and procedures. This document is only a partial listing of benefits. This is not a contract of insurance. No person other than an officer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or certificate will contain the complete listing of covered services. • Diabetic Supplies o Retail: only needles/syringes are covered o Home Delivery/Mail Order: all diabetic supplies are covered, including needles/syringes, blood/urine test strips, lancets, alcohol swabs/wipes • Coverage Management Programs included – Prior Approval, Step Therapy and Quantity Duration 1Proton Pump Inhibitors (PPI’s) are a class of drugs that inhibit gastric acid production and are used to treat a variety of gastrointestinal conditions. 2Coverage includes Preventive Medications, in accordance with Federal Law. 3If your Prescription Order is for a Prescription Drug that is available through the Home Delivery Prescription Drug program and you choose not to use the Home Delivery Prescription Drug program, no benefit will be provided when your Prescription Order is filled beyond the third fill. NAME DATE POSITION POSITION_ SCHOOL Competency A: Demonstrates the ability to plan and deliver guidance services. S U Comments: Competency B: Demonstrates knowledge of counseling techniques and student development. S U Comments: Competency C: Demonstrates the ability to utilize group management techniques. S U Comments: Competency D: Shows sensitivity to student needs by maintaining a positive school climate. S U Comments: Competency E: Demonstrates ability to assess student/program needs for academic support. S U Comments: Competency F: Demonstrates ability to communicate effectively with parents, students, teachers, and administrators. S U Comments: Competency G: Demonstrates willingness to assume general professional responsibilities. S U Comments: Competency H: Demonstrates a commitment to professional growth. S U Comments: Competency I: Shows evidence of professional characteristics. S U Comments: OVERALL EVALUATION: S U Not accepted. My signature evidences receipt of this document only. I have read this document and understand the contents. School Counselor’s Signature / Date Counselor (name) School (name) Observer Date Beg. Time End Time Directions: This instrument is to be used for the minimum observation period of thirty minutes. Place a check by the indicator number when the behavior is observed. Place an “X” observed, but outside of observation time frame. Use the Comments/Recommendations space for descriptive notes.

Leave for Relatives of Military Personnel. It is the responsibility of the employee, upon his/her return to school, to fill out an absence report. Superintendent’s Signature Date Benefit Period January 1st through December 31st Dependent Age Limit 19 Dependent / 00 Xxxxxxx Xxxxxxx xxxx Xxx of Month Blood Pint Deductible 0 pints Lifetime Maximum $2,000,000 Benefit Period Deductible – Single/Family1 $500/$1,000 $500/$1,000 Coinsurance 90% 80% Coinsurance Maximum – Single/Family1 $500/$1,000 $1,000/$2,000 Coinsurance Out-of-Pocket Maximum (Including Deductible) – Single/Family $1,000/$2,000 $1,500/$3,000 Office Visit (Illness/Injury)2 $20 copay, then 100% $20 copay, then 80% Urgent Care Office Visit2 $20 copay, then 100% $20 copay, then 80% Routine Services Routine Physical Exams (Ages nine and over)2 $20 copay, then 100% $20 copay, then 80% Well Child Care Services including Exam, Immunizations and Laboratory Tests (Birth to age nine, limited to a $500 maximum per benefit period)2 Exam - $20 copay, then 100% Immunizations/Labs – 90% - Not subject to deductible $20 copay, then 80% Immunizations/Labs – 80% - Not subject to deductible Routine Mammogram (One per benefit period) 90% not subject to deductible 80% not subject to deductible Routine Pap Test (One per benefit period) 90% not subject to deductible 80% not subject to deductible Routine Prostate Specific Antigen (PSA) 90% not subject to deductible 80% not subject to deductible Routine Endoscopies 90% not subject to deductible 80% not subject to deductible All Routine X-rays, Medical Tests and Laboratory Tests (Ages nine and over) 90% not subject to deductible 80% not subject to deductible Surgical Services 90% after deductible 80% after deductible Diagnostic Services 90% after deductible 80% after deductible Physical & Occupational Therapy – Facility and Professional (40 visits combined per benefit period) 90% after deductible 80% after deductible Chiropractic Therapy – Professional Only (12 visits per benefit period) 50% after deductible 50% after deductible Speech Therapy – Facility and Professional (20 visits per benefit period) 90% after deductible 80% after deductible Cardiac Rehabilitation 90% after deductible 80% after deductible Emergency use of an Emergency Room3 75% copay, then 100% Non-Emergency use of an Emergency Room4 $75 copay, then 90% $75 copay, then 80% Semi-Private Room and Board – Including Ancillaries (365 days per in-hospital benefit period)5 90% after deductible 80% after deductible Maternity 90% after deductible 80% after deductible Skilled Nursing Facility (Two days available for each unused in-hospital day) 90% after deductible 80% after deductible Human Organ Transplants 90% after deductible 80% after deductible Allergy Testing and Treatments 90% after deductible 80% after deductible Ambulance – air if medically necessary 90% after deductible 80% after deductible Durable Medical Equipment 90% after deductible 80% after deductible Home Healthcare 90% after deductible 80% after deductible Hospice Services 90% after deductible 80% after deductible Private Duty Nursing 90% after deductible 80% after deductible Inpatient Mental Health and Substance Abuse Services (31 days per benefit period; Substance Abuse limited to 3 admissions per Lifetime) 90% after deductible 80% after deductible Outpatient Mental Health and Substance Abuse Services (50 visits per benefit period) 50% after deductible 50% after deductible Note: Services requiring a copayment are not subject to the single/family deductible. Deductible and coinsurance expenses incurred for services by a non-network provider will also apply to the network deductible and coinsurance out-of-pocket limits. Deductible and coinsurance expenses incurred for services by a network provider will also apply to the non-network deductible and coinsurance out-of-pocket limits. Non-Contracting and Facility Other Providers will pay the same as Non-Network. Benefits will be determined based on Medical Mutual’s medical and administrative policies and procedures. This document is only a partial listing of benefits. This is not a contract of insurance. No person other than an officer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or certificate will contain the complete listing of covered services. In certain instances, Medical Mutual’s payment may not equal the percentage listed above. However, the covered person’s coinsurance will always be based on the lesser of the provider’s billed charges or Medical Mutual’s negotiated rate with the provider. 1Maximum family deductible. Member deductible is the same as single deductible. 4th quarter carryover applies. 2The office visit copay applies to the cost of the office visit only. 3Copay waived if admitted. The copay applies to room charges only. All other covered charges are not subject to deductible. 4Copay waived if admitted. The copay applies to room charges only. All other covered charges are subject to deductible and coinsurance. 5An in-hospital benefit period is a period of time beginning when the member enters a hospital and ending when he/she has been out for 90 consecutive days. Benefit Period January 1st through December 31st Dependent Age Limit Same as Medical Generic Copayment $10 30 Brand Name Copayment $25 30 Generic Copayment $20 90 Brand Name Copayment $50 90 Note: Benefits will be determined based on Medical Mutual’s medical and administrative policies and procedures. This document is only a partial listing of benefits. This is not a contract of insurance. No person other than an officer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or certificate will contain the complete listing of covered services.  Oral Contraceptives are covered  Diabetic Supplies o Retail: only needles/syringes are covered o Home Delivery/Mail Order: all diabetic supplies are covered, including needles/syringes, blood/urine test strips, lancets, alcohol swabs/wipes Benefit Period January 1st through December 31st Dependent Age Limit 26 Removal upon End of Month Blood Pint Deductible 0 pints Overall Annual Benefit Period Maximum Unlimited Wellness Plan Deductible – Single/Family1 $500/$1,000 $500/$1,000 High Deductible Health Plan – Single/Family1 $750/$1,500 $750/$1,500 Requirements for Wellness Plan (Deductible changes occurs on calendar year basis) Complete Screening and/or Physician form and Health Assessment – November 1st. Complete Screening and/or Physician form and Health Assessment – November 1st. Coinsurance 90% 70% Coinsurance Out-of-Pocket Maximum (Excluding Deductible) – Single/Family $1,000/$2,000 (Wellness) $750/$1,500 (HDHP) $2,500/$5,000 (Wellness) $2,250/$4,500 (HDHP) Coinsurance Out-of-Pocket Maximum (Including Deductible) – Single/Family $1,500/$3,000 (Wellness) $1,500/$3,000 (HDHP) $3,000/$6,000 (Wellness) $3,000/$6,000 (HDHP) Office Visit (Illness/Injury)2 $25 copay, then 100% $25 copay, then 70% Specialist Office Visit2 $40 copay, then 100% $40 copay, then 70% Urgent Care Office Visit2 $40 copay, then 100% $40 copay, then 70% Preventive Services in accordance with federal law6 100% 70% after deductible Routine Physical Exams 2 100% $25 copay, then 70% Well Child Care Services including Exam, Routine Vision, Routine Hearing Exams, Well Child Care Immunizations and Laboratory Tests (Birth to age 21, Unlimited) 100% $25 copay, then 70% Routine Mammogram (One per benefit period) 100% 70% not subject to deductible Routine Pap Test (One per benefit period) 100% 70% not subject to deductible Routine Prostate Specific Antigen (PSA) 100% 70% not subject to deductible Routine Endoscopies 100% 70% not subject to deductible All Routine X-rays, Medical Tests and Laboratory Tests 100% 70% not subject to deductible Surgical Services 90% after deductible 70% after deductible Diagnostic Services 90% after deductible 70% after deductible Physical & Occupational Therapy – Facility and Professional (40 visits combined per benefit period) 90% after deductible 70% after deductible Chiropractic Therapy – Professional Only (12 visits per benefit period) 50% after deductible 50% after deductible Speech Therapy – Facility and Professional (20 visits per benefit period) 90% after deductible 70% after deductible Cardiac Rehabilitation 90% after deductible 70% after deductible Emergency use of an Emergency Room3 $100 copay, then 100% Non-Emergency use of an Emergency Room4 $200 copay, then 90% $200 copay, then 70% Semi-Private Room and Board – Including Ancillaries (365 days per in-hospital benefit period)5 90% after deductible 70% after deductible Maternity 90% after deductible 70% after deductible Skilled Nursing Facility (Two days available for each unused in-hospital day) 90% after deductible 70% after deductible Human Organ Transplants 90% after deductible 70% after deductible Allergy Testing and Treatments 90% after deductible 70% after deductible Ambulance – air if medically necessary 90% after deductible 70% after deductible Durable Medical Equipment 90% after deductible 70% after deductible Home Healthcare 90% after deductible 70% after deductible Hospice Services 90% after deductible 70% after deductible Private Duty Nursing 90% after deductible 70% after deductible Inpatient Mental Health and Substance Abuse Services Benefits paid are based on corresponding medical benefits Outpatient Mental Health and Substance Abuse Services Note: Services requiring a copayment are not subject to the single/family deductible. Deductible and coinsurance expenses incurred for services by a non-network provider will also apply to the network deductible and deductibleand coinsurance out-of-pocket limits. Deductible and coinsurance expenses incurred for services by a network provider will also apply to the non-network deductible and coinsurance out-of-pocket limits. Non-Contracting and Facility Other Providers will pay the same as Non-Network. Benefits will be determined based on Medical Mutual’s medical and administrative policies and procedures. This document is only a partial listing of benefits. This is not a contract of insurance. No person other than an officer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or certificate will contain the complete listing of covered services. In certain instances, Medical Mutual’s payment may not equal the percentage listed above. However, the covered person’s coinsurance will always be based on the lesser of the provider’s billed charges or Medical Mutual’s negotiated rate with the provider. 1Maximum family deductible. Member deductible is the same as single deductible. 4th quarter carryover applies. 2The office visit copay applies to the cost of the office visit only. 3Copay waived if admitted. The copay applies to room charges only. All other covered charges are not subject to deductible. 4Copay waived if admitted. The copay applies to room charges only. All other covered charges are subject to deductible and coinsurance. 5An in-hospital benefit period is a period of time beginning when the member enters a hospital and ending when he/she has been out for 90 consecutive days. 6Preventive services include evidence-based services that have a rating of “A” or “B” in the United States Preventive Services Task Force, routine immunizations and other screenings, as provided for in the Patient Protection and Affordable Care Act. Wellness Ideal Plan – Non-Grandfathered Benefit Period January 1st through December 31st Dependent Age Limit 26 / Removal upon End of Month Proton Pump Inhibitors (i.e., Prilosec OTC – Omeprazole)1 $0 30 Retail Program3 Immunization and Generic Contraceptives2 $0 N/A Generic Copayment $7.50 30 Formulary Copayment $25 30 Non-Formulary Copayment $50 30 Home Delivery Program3 Generic Copayment $15 90 Formulary Copayment $50 90 Non-Formulary Copayment $100 90 Note: Benefits will be determined based on Medical Mutual’s medical and administrative policies and procedures. This document is only a partial listing of benefits. This is not a contract of insurance. No person other than an officer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or certificate will contain the complete listing of covered services. •  Diabetic Supplies o Retail: only needles/syringes are covered o Home Delivery/Mail Order: all diabetic supplies are covered, including needles/syringes, blood/urine test strips, lancets, alcohol swabs/wipes •  Coverage Management Programs included – Prior Approval, Step Therapy and Quantity Duration participating in MMO’s Diabetes Advantage program. If you have questions about the program and/or wish to enroll, please call 0-000-000-0000. 1Proton Pump Inhibitors (PPI’s) are a class of drugs that inhibit gastric acid production and are used to treat a variety of gastrointestinal conditions. 2Coverage includes Preventive Medications, in accordance with Federal Law. 3If your Prescription Order is for a Prescription Drug that is available through the Home Delivery Prescription Drug program and you choose not to use the Home Delivery Prescription Drug program, no benefit will be provided when your Prescription Order is filled beyond the third fill. NAME DATE POSITION POSITION_ SCHOOL Competency A: Demonstrates the ability to plan and deliver guidance services. S U Comments: Competency B: Demonstrates knowledge of counseling techniques and student development. S U Comments: Competency C: Demonstrates the ability to utilize group management techniques. S U Comments: Competency D: Shows sensitivity to student needs by maintaining a positive school climate. S U Comments: Competency E: Demonstrates ability to assess student/program needs for academic support. S U Comments: Competency F: Demonstrates ability to communicate effectively with parents, students, teachers, and administrators. S U Comments: Competency G: Demonstrates willingness to assume general professional responsibilities. S U Comments: Competency H: Demonstrates a commitment to professional growth. S U Comments: Competency I: Shows evidence of professional characteristics. S U Comments: OVERALL EVALUATION: S U Not accepted. My signature evidences receipt of this document only. I have read this document and understand the contents. School Counselor’s Signature / Date Counselor (name) School (name) Observer Date Beg. Time End Time Directions: This instrument is to be used for the minimum observation period of thirty minutes. Place a check by the indicator number when the behavior is observed. Place an “X” observed, but outside of observation time frame. Use the Comments/Recommendations space for descriptive notes.

Leave for Relatives of Military Personnel. It is the responsibility of the employee, upon his/her return to school, to fill out an absence report. Benefit Period January 1st through December 31st Dependent Age Limit 19 Dependent / 25 Student Removal upon End of Month Blood Pint Deductible 0 pints Lifetime Maximum $2,000,000 Benefit Period Deductible – Single/Family1 $500/$1,000 $500/$1,000 Coinsurance 90% 80% Coinsurance Maximum – Single/Family1 $500/$1,000 $1,000/$2,000 Coinsurance Out-of-Pocket Maximum (Including Deductible) – Single/Family $1,000/$2,000 $1,500/$3,000 Office Visit (Illness/Injury)2 $20 copay, then 100% $20 copay, then 80% Urgent Care Office Visit2 $20 copay, then 100% $20 copay, then 80% Routine Services Routine Physical Exams (Ages nine and over)2 $20 copay, then 100% $20 copay, then 80% Well Child Care Services including Exam, Immunizations and Laboratory Tests (Birth to age nine, limited to a $500 maximum per benefit period)2 Exam - $20 copay, then 100% Immunizations/Labs – 90% - Not subject to deductible $20 copay, then 80% Immunizations/Labs – 80% - Not subject to deductible Routine Mammogram (One per benefit period) 90% not subject to deductible 80% not subject to deductible Routine Pap Test (One per benefit period) 90% not subject to deductible 80% not subject to deductible Routine Prostate Specific Antigen (PSA) 90% not subject to deductible 80% not subject to deductible Routine Endoscopies 90% not subject to deductible 80% not subject to deductible All Routine X-rays, Medical Tests and Laboratory Tests (Ages nine and over) 90% not subject to deductible 80% not subject to deductible Surgical Services 90% after deductible 80% after deductible Diagnostic Services 90% after deductible 80% after deductible Physical & Occupational Therapy – Facility and Professional (40 visits combined per benefit period) 90% after deductible 80% after deductible Chiropractic Therapy – Professional Only (12 visits per benefit period) 50% after deductible 50% after deductible Speech Therapy – Facility and Professional (20 visits per benefit period) 90% after deductible 80% after deductible Cardiac Rehabilitation 90% after deductible 80% after deductible Emergency use of an Emergency Room3 75% copay, then 100% Non-Emergency use of an Emergency Room4 $75 copay, then 90% $75 copay, then 80% Semi-Private Room and Board – Including Ancillaries (365 days per in-hospital benefit period)5 90% after deductible 80% after deductible Maternity 90% after deductible 80% after deductible Skilled Nursing Facility (Two days available for each unused in-hospital day) 90% after deductible 80% after deductible Human Organ Transplants 90% after deductible 80% after deductible Allergy Testing and Treatments 90% after deductible 80% after deductible Ambulance – air if medically necessary 90% after deductible 80% after deductible Durable Medical Equipment 90% after deductible 80% after deductible Home Healthcare 90% after deductible 80% after deductible Hospice Services 90% after deductible 80% after deductible Private Duty Nursing 90% after deductible 80% after deductible Inpatient Mental Health and Substance Abuse Services (31 days per benefit period; Substance Abuse limited to 3 admissions per Lifetime) 90% after deductible 80% after deductible Outpatient Mental Health and Substance Abuse Services (50 visits per benefit period) 50% after deductible 50% after deductible Note: Services requiring a copayment are not subject to the single/family deductible. Deductible and coinsurance expenses incurred for services by a non-network provider will also apply to the network deductible and coinsurance out-of-pocket limits. Deductible and coinsurance expenses incurred for services by a network provider will also apply to the non-network deductible and coinsurance out-of-pocket limits. Non-Contracting and Facility Other Providers will pay the same as Non-Network. Benefits will be determined based on Medical Mutual’s medical and administrative policies and procedures. This document is only a partial listing of benefits. This is not a contract of insurance. No person other than an officer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or certificate will contain the complete listing of covered services. In certain instances, Medical Mutual’s payment may not equal the percentage listed above. However, the covered person’s coinsurance will always be based on the lesser of the provider’s billed charges or Medical Mutual’s negotiated rate with the provider. 1Maximum family deductible. Member deductible is the same as single deductible. 4th quarter carryover applies. 2The office visit copay applies to the cost of the office visit only. 3Copay waived if admitted. The copay applies to room charges only. All other covered charges are not subject to deductible. 4Copay waived if admitted. The copay applies to room charges only. All other covered charges are subject to deductible and coinsurance. 5An in-hospital benefit period is a period of time beginning when the member enters a hospital and ending when he/she has been out for 90 consecutive days. Benefit Period January 1st through December 31st Dependent Age Limit Same as Medical Generic Copayment $10 30 Brand Name Copayment $25 30 Generic Copayment $20 90 Brand Name Copayment $50 90 Note: Benefits will be determined based on Medical Mutual’s medical and administrative policies and procedures. This document is only a partial listing of benefits. This is not a contract of insurance. No person other than an officer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or certificate will contain the complete listing of covered services. • Oral Contraceptives are covered • Diabetic Supplies o Retail: only needles/syringes are covered o Home Delivery/Mail Order: all diabetic supplies are covered, including needles/syringes, blood/urine test strips, lancets, alcohol swabs/wipes Benefit Period January 1st through December 31st Dependent Age Limit 26 Removal upon End of Month Blood Pint Deductible 0 pints Overall Annual Benefit Period Maximum Unlimited Wellness Plan Deductible – Single/Family1 $500/$1,000 $500/$1,000 High Deductible Health Plan – Single/Family1 $750/$1,500 $750/$1,500 Requirements for Wellness Plan (Deductible changes occurs on calendar year basis) Complete Screening and/or Physician form and Health Assessment – November 1st. Complete Screening and/or Physician form and Health Assessment – November 1st. Coinsurance 90% 70% Coinsurance Out-of-Pocket Maximum (Excluding Deductible) – Single/Family $1,000/$2,000 (Wellness) $750/$1,500 (HDHP) $2,500/$5,000 (Wellness) $2,250/$4,500 (HDHP) Coinsurance Out-of-Pocket Maximum (Including Deductible) – Single/Family $1,500/$3,000 (Wellness) $1,500/$3,000 (HDHP) $3,000/$6,000 (Wellness) $3,000/$6,000 (HDHP) Office Visit (Illness/Injury)2 $25 copay, then 100% $25 copay, then 70% Specialist Office Visit2 $40 copay, then 100% $40 copay, then 70% Urgent Care Office Visit2 $40 copay, then 100% $40 copay, then 70% Preventive Services in accordance with federal law6 100% 70% after deductible Routine Physical Exams 2 100% $25 copay, then 70% Well Child Care Services including Exam, Routine Vision, Routine Hearing Exams, Well Child Care Immunizations and Laboratory Tests (Birth to age 21, Unlimited) 100% $25 copay, then 70% Routine Mammogram (One per benefit period) 100% 70% not subject to deductible Routine Pap Test (One per benefit period) 100% 70% not subject to deductible Routine Prostate Specific Antigen (PSA) 100% 70% not subject to deductible Routine Endoscopies 100% 70% not subject to deductible All Routine X-rays, Medical Tests and Laboratory Tests 100% 70% not subject to deductible Surgical Services 90% after deductible 70% after deductible Diagnostic Services 90% after deductible 70% after deductible Physical & Occupational Therapy – Facility and Professional (40 visits combined per benefit period) 90% after deductible 70% after deductible Chiropractic Therapy – Professional Only (12 visits per benefit period) 50% after deductible 50% after deductible Speech Therapy – Facility and Professional (20 visits per benefit period) 90% after deductible 70% after deductible Cardiac Rehabilitation 90% after deductible 70% after deductible Emergency use of an Emergency Room3 $100 copay, then 100% Non-Emergency use of an Emergency Room4 $200 copay, then 90% $200 copay, then 70% Semi-Private Room and Board – Including Ancillaries (365 days per in-hospital benefit period)5 90% after deductible 70% after deductible Maternity 90% after deductible 70% after deductible Skilled Nursing Facility (Two days available for each unused in-hospital day) 90% after deductible 70% after deductible Human Organ Transplants 90% after deductible 70% after deductible Allergy Testing and Treatments 90% after deductible 70% after deductible Ambulance – air if medically necessary 90% after deductible 70% after deductible Durable Medical Equipment 90% after deductible 70% after deductible Home Healthcare 90% after deductible 70% after deductible Hospice Services 90% after deductible 70% after deductible Private Duty Nursing 90% after deductible 70% after deductible Inpatient Mental Health and Substance Abuse Services Benefits paid are based on corresponding medical benefits Outpatient Mental Health and Substance Abuse Services Note: Services requiring a copayment are not subject to the single/family deductible. Deductible and coinsurance expenses incurred for services by a non-network provider will also apply to the network deductible and deductibleand coinsurance out-of-pocket limits. Deductible and coinsurance expenses incurred for services by a network provider will also apply to the non-network deductible and coinsurance out-of-pocket limits. Non-Contracting and Facility Other Providers will pay the same as Non-Network. Benefits will be determined based on Medical Mutual’s medical and administrative policies and procedures. This document is only a partial listing of benefits. This is not a contract of insurance. No person other than an officer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or certificate will contain the complete listing of covered services. In certain instances, Medical Mutual’s payment may not equal the percentage listed above. However, the covered person’s coinsurance will always be based on the lesser of the provider’s billed charges or Medical Mutual’s negotiated rate with the provider. 1Maximum family deductible. Member deductible is the same as single deductible. 4th quarter carryover applies. 2The office visit copay applies to the cost of the office visit only. 3Copay waived if admitted. The copay applies to room charges only. All other covered charges are not subject to deductible. 4Copay waived if admitted. The copay applies to room charges only. All other covered charges are subject to deductible and coinsurance. 5An in-hospital benefit period is a period of time beginning when the member enters a hospital and ending when he/she has been out for 90 consecutive days. 6Preventive services include evidence-based services that have a rating of “A” or “B” in the United States Preventive Services Task Force, routine immunizations and other screenings, as provided for in the Patient Protection and Affordable Care Act. Wellness Ideal Plan – Non-Grandfathered Benefit Period January 1st through December 31st Dependent Age Limit 26 / Removal upon End of Month Proton Pump Inhibitors (i.e., Prilosec OTC – Omeprazole)1 $0 30 Retail Program3 Immunization and Generic Contraceptives2 $0 N/A Generic Copayment $7.50 30 Formulary Copayment $25 30 Non-Formulary Copayment $50 30 Home Delivery Program3 Generic Copayment $15 90 Formulary Copayment $50 90 Non-Formulary Copayment $100 90 Note: Benefits will be determined based on Medical Mutual’s medical and administrative policies and procedures. This document is only a partial listing of benefits. This is not a contract of insurance. No person other than an officer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or certificate will contain the complete listing of covered services. • Diabetic Supplies o Retail: only needles/syringes are covered o Home Delivery/Mail Order: all diabetic supplies are covered, including needles/syringes, blood/urine test strips, lancets, alcohol swabs/wipes • Coverage Management Programs included – Prior Approval, Step Therapy and Quantity Duration 1Proton Pump Inhibitors (PPI’s) are a class of drugs that inhibit gastric acid production and are used to treat a variety of gastrointestinal conditions. 2Coverage includes Preventive Medications, in accordance with Federal Law. 3If your Prescription Order is for a Prescription Drug that is available through the Home Delivery Prescription Drug program and you choose not to use the Home Delivery Prescription Drug program, no benefit will be provided when your Prescription Order is filled beyond the third fill. NAME DATE POSITION SCHOOL Competency A: Demonstrates the ability to plan and deliver guidance services. S U Comments: Competency B: Demonstrates knowledge of counseling techniques and student development. S U Comments: Competency C: Demonstrates the ability to utilize group management techniques. S U Comments: Competency D: Shows sensitivity to student needs by maintaining a positive school climate. S U Comments: Competency E: Demonstrates ability to assess student/program needs for academic support. S U Comments: Competency F: Demonstrates ability to communicate effectively with parents, students, teachers, and administrators. S U Comments: Competency G: Demonstrates willingness to assume general professional responsibilities. S U Comments: Competency H: Demonstrates a commitment to professional growth. S U Comments: Competency I: Shows evidence of professional characteristics. S U Comments: OVERALL EVALUATION: S U Not accepted. My signature evidences receipt of this document only. I have read this document and understand the contents. School Counselor’s Signature / Date Counselor (name) School (name) Observer Date Beg. Time End Time Directions: This instrument is to be used for the minimum observation period of thirty minutes. Place a check by the indicator number when the behavior is observed. Place an “X” observed, but outside of observation time frame. Use the Comments/Recommendations space for descriptive notes.