Common use of Precertification Clause in Contracts

Precertification. Members are encouraged to always obtain prior approval when using non-network providers. Precertification will help avoid any unnecessary reduction in benefits for non-covered or non-medically necessary services. Pre-existing Exclusion Period: We will not provide benefits for services, supplies or charges for any pre-existing condition for the time period specified below (subject to HIPAA portability requirements and excludes members under age 19): 12 months after the member’s enrollment date A pre-existing condition is a condition (mental or physical) which was present and for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period ending on the member’s enrollment date. Pregnancy and domestic violence are not considered a pre-existing condition. Genetic information may not be used as a condition in the absence of a diagnosis. Benefit Summary – Dental Blue Access 100/200/300 Annual Deductible Individual/Family Combined In and Out of Network Annual Maximum $50 Individual / $100 Family $ 1,500 Services PPO Dentists (In-network) Non-PPO (Out-of-network) Diagnostic and preventive NCS/No deductible NCS/No deductible 🞈 🞈 Oral evaluations, x-rays, Cleanings Sealants and fluoride, Space maintainers Minor restorative 30% after deductible 30% after deductible 🞈 Emergency palliative pain treatment 🞈 Amalgam restorations (fillings), Composite restoration (fillings) 🞈 Sedative fillings Oral surgery 30% after deductible 30% after deductible 🞈 Simple extractions, Removal of impacted teeth, General anesthesia Endodontic services 30% after deductible 30% after deductible 🞈 Root Canal Therapy, Therapeutic pulpotomy, Direct pulp capping Periodontal services 30% after deductible 30% after deductible 🞈 Scaling and root planing, Gingivectomy, Osseous surgery, Soft tissue grafts Prosthodontic Services 40% after deductible 40% after deductible 🞈 Crowns, Removable complete and partial dentures 🞈 Bridge repair 🞈 Implants Not Covered Not Covered 🞈 Missing Teeth Covered Covered Orthodontic Services 40%/No deductible 40%/No deductible 🞈 🞈 Examinations, Records Tooth guidance, Repositioning (straightening) of the teeth Orthodontic Maximum $1,500 Orthodontic Age Limit Adult & Child to Age 19 Limitations — Below is a partial listing of some of the limitations. Please see Certificate for full list: • Oral Evaluations. Limited to two per year. • Prophylaxis or Periodontal Maintenance Procedure. Limited to two treatments per year, singly or in combination. • Fluoride treatments. Limited to two per year for children up to age 19. • X-rays. Limited to one set of full-mouth x-rays or its equivalent once every five years. Periapical x-rays are limited to 4 films per year. • Bitewing X-rays. Limited to one set of up to 4 films twice per year to age 19 and once per year thereafter. • Sealants. Limited to children under 16 years of age for permanent unrestored first and second molars. Treatment is limited to two applications per tooth per lifetime.

Precertification. Members are encouraged to always obtain prior approval when using non-network providers. Precertification will help avoid any unnecessary reduction in benefits for non-covered or non-medically necessary services. Pre-existing Exclusion Period: We will not provide This summary of benefits for serviceshas been updated to comply with federal and state requirements, supplies or charges for any pre-existing condition for including applicable provisions of the time period specified below (subject to HIPAA portability requirements recently enacted federal health care reform laws. As we receive additional guidance and excludes members under age 19): 12 months after the member’s enrollment date A pre-existing condition is a condition (mental or physical) which was present and for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period ending clarification on the member’s enrollment date. Pregnancy new health care reform laws from the U.S. Department of Health and domestic violence are not considered a pre-existing condition. Genetic information Human Services, Department of Labor and Internal Revenue Service, we may not be used as a condition in the absence required to make additional changes to this summary of a diagnosisbenefits. Benefit Summary – - Dental Blue Access 100/200/300 Annual Deductible $50 Individual / $100 Family Individual/Family Combined In and Out of Network Annual Maximum $50 Individual / $100 Family Maximum Carryover Provision $ 1,500 Not Included Out of Network Reimbursement 90th percentile Services PPO Dentists (In-network) Non-PPO (Out-of-network) Diagnostic and preventive NCS/No deductible NCS/No deductible 🞈 🞈 Oral evaluations, x-rays, Cleanings Sealants and fluoride, Space maintainers Minor restorative 30% after deductible 30% after deductible 🞈 Emergency palliative pain treatment 🞈 Amalgam restorations (fillings), Composite restoration (fillings) 🞈 Sedative fillings Oral surgery 30% after deductible 30% after deductible 🞈 Simple extractions, Removal of impacted teeth, General anesthesia Endodontic services 30% after deductible 30% after deductible 🞈 Root Canal Therapy, Therapeutic pulpotomy, Direct pulp capping Periodontal services 30% after deductible 30% after deductible 🞈 Scaling and root planing, Gingivectomy, Osseous surgery, Soft tissue grafts Prosthodontic Services 40% after deductible 40% after deduc🞈 🞈 🞈 tible 🞈 Crowns, Removable complete and partial dentures 🞈 Bridge repair �Missing Teeth � Implants NCovered ot Covered Not Covered 🞈 Missing Teeth Covered Covered Orthodontic Services 40%/No deductible 40%/No deductible 🞈 🞈 Examinations, Records Tooth guidance, Repositioning (straightening) of the teeth Orthodontic Maximum $1,500 Orthodontic Age &Limit Adult & Child to Age 19 Limitations — Below is a partial listing of some of the limitations. Please see Certificate for full list: • Oral Evaluations. Limited to two per year. • Prophylaxis or Periodontal Maintenance Procedure. Limited to two treatments per year, singly or in combination. • Fluoride treatments. Limited to two per year for children up to age 19. • X-rays. Limited to one set of full-mouth x-rays or its equivalent once every five years. Periapical x-rays are limited to 4 films per year. • Bitewing X-rays. Limited to one set of up to 4 films twice per year to age 19 and once per year thereafter. • Sealants. Limited to children under 16 years of age for permanent unrestored first and second molars. Treatment is limited to two applications per tooth per lifetime.

Precertification. Members are encouraged to always obtain prior approval when using non-network providers. Precertification will help avoid any unnecessary reduction in benefits for non-covered or non-medically necessary services. Pre-existing Exclusion Period: We will not provide benefits for services, supplies or charges for any pre-existing condition for the time period specified below (subject to HIPAA portability requirements and excludes members under age 19): 12 months after the member’s enrollment date A pre-existing condition is a condition (mental or physical) which was present and for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period ending on the member’s enrollment date. Pregnancy and domestic violence are not considered a pre-existing condition. Genetic information may not be used as a condition in the absence of a diagnosis. Benefit Summary – Dental Blue Access 100/200/300 Annual Deductible Individual/Family Combined In and Out of Network Annual Maximum $50 Individual / $100 Family $ 1,500 Services PPO Dentists (In-network) Non-PPO (Out-of-network) Diagnostic and preventive NCS/No deductible NCS/No deductible 🞈 � � Oral evaluations, x-rays, Cleaning s Sealants and fluoride, Space maintainers Minor restorative 30% after deductible 30% after deductible  🞈 Emergency palliative pain treatment 🞈 Amalgam restorations (fillings), Composite restoration (fillings ) 🞈 Sedative fillings Oral surgery 30% after deductible 30% after deductib le 🞈 Simple extractions, Removal of impacted teeth, General anesthesia Endodontic services 30% after deductible 30% after deducti ble 🞈 Root Canal Therapy, Therapeutic pulpotomy, Direct pulp capping Periodontal services 30% after deductible 30% after deduct ible 🞈 Scaling and root planing, Gingivectomy, Osseous surgery, Soft tissue grafts Prosthodontic Services 40% after deductible 40% after deduc tible 🞈 Crowns, Removable complete and partial de ntures 🞈 Bridge repair 🞈 Implants Not Covered Not Covered 🞈 Missing Teeth Covered Covered Orthodontic Services 40%/No deductible 40%/No ded uctible 🞈 🞈 Examinat ions, Records Tooth guidance, Repositioning (straightening) of the teeth Orthodontic Maximum $1,500 Orthodontic Age Limit Adult & Child to Age 19 Limitations — Below is a partial listing of some of the limitations. Please see Certificate for full list: • Oral Evaluations. Limited to two per year. • Prophylaxis or Periodontal Maintenance Procedure. Limited to two treatments per year, singly or in combination. • Fluoride treatments. Limited to two per year for children up to age 19. • X-rays. Limited to one set of full-mouth x-rays or its equivalent once every five years. Periapical x-rays are limited to 4 films per year. • Bitewing X-rays. Limited to one set of up to 4 films twice per year to age 19 and once per year thereafter. • Sealants. Limited to children under 16 years of age for permanent unrestored first and second molars. Treatment is limited to two applications per tooth per lifetime.

Precertification. Members are encouraged to always obtain prior approval when using non-network providers. Precertification will help avoid any unnecessary reduction in benefits for non-covered or non-medically necessary services. Pre-existing Exclusion Period: We will not provide benefits for services, supplies or charges for any pre-existing condition for the time period specified below (subject to HIPAA portability requirements and excludes members under age 19): 12 months after the member’s enrollment date A pre-existing condition is a condition (mental or physical) which was present and for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period ending on the member’s enrollment date. Pregnancy and domestic violence are not considered a pre-existing condition. Genetic information may not be used as a condition in the absence of a diagnosis. Benefit Summary – Delta Dental Blue Access 100/200/300 Annual Deductible Individual/Family Combined In and Out of Network Annual Maximum $50 Individual / $100 Family $ 1,500 Services PPO Dentists (In-network) Non-PPO (OutPoint-of-networkService) Summary of Dental Plan Benefits For Group #1039-0001, 0002, 0003, 0099 Pickerington Local School District This Summary of Dental Plan Benefits should be read in conjunction with your Dental Care Certificate. Your Dental Care Certificate will provide you with additional information about your Delta Dental plan, including information about plan exclusions and limitations. The percentages below will be applied to the lesser of the dentist’s submitted fee and Delta Dental’s allowance for each service. Delta Dental’s allowance may vary by the dentist’s network participation. PLEASE NOTE – if you choose a Nonparticipating Dentist, you will be responsible for any difference between the amount Delta Dental allows and the amount the Nonparticipating Dentist charges, in addition to any Co-payment or Deductible. Control Plan – Delta Dental of Ohio Benefit Year – January 1 through December 1 Covered Services PPO Dentist Premier Dentist Non- participating Dentist Plan Pays Plan Pays Plan Pays* Class I Diagnostic and preventive NCS/No deductible NCS/No deductible 🞈 🞈 Oral evaluatioPreventive Services – includes examsns, x-racleaningsys, Cleanings Sealants and fluoride, Spacand space e maintainer100% 100% 100% Emergency Palliative Treatment – to temporarily relieve pain 100% 100% 100% Sealants – to prevent decay of permanent teeth 100% 100% 100% Radiographs – X-rays 100% 100% 100% Class II s Minor restorative Restorative Services – fillings and crown repair 8030% after deductible 8030% after deductible 🞈 Emergency palliative pain treatment 🞈 Amalgam restorations (fillings), Composite restoration (fillings) 🞈 Sedative fill80% Endodontic Services – root canals 80% 80% 80% Periodontic Services – to treat gum disease 80% 80% 80% ings Surgery Services – extractions and dental Oral surge80ry 30% after deductib80le 30% after deductible 🞈 Simple extractions, Removal of impacted teeth, General anesthesia Endod80% Other Basic Services – misc. ontic servi80ces 30% after deducti80ble 30% after deductible 🞈 Root Canal Therapy, Therapeutic pulpotomy, Direct pulp capping Periodontal serv80ices 30% after deductRelines and Repairs – to bridges and dentures 80ible 30% after deductible 🞈 Scaling and root planing, Gingivectomy, Osseous surgery, Soft tissue80% 80% Class III Major Restorative Services – crowns 60% 60% 60% grafts Prosthodontic Ser– includes bridges and dentures 60vices 40% after deduc60tible 40% after deductible 🞈 Crowns, Removable complete and partial dentures 🞈 Bridge repair 🞈 Implants Not Covered Not Covered 🞈 Missing Teeth Cove60% Class IV red Covered Orthodontic Services 40%/No deductible 40%/No deductible 🞈 🞈 Examinations, Records Tooth guidance, Repositioning (straightening) of the teeth Orthodontic M– includes braces 60% 60% 60% aximum $1,500 Orthodontic Age Limit No Age Limit No Age Limit No Age Limit *When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental’s Nonparticipating Dentist Fee that will be paid for those services. This Nonparticipating Dentist Fee may be less than what your dentist charges, which means that you will be responsible for the difference. Maximum Payment - $2,500 per person total per benefit year on all services except orthodontics. $850 per person total per lifetime on orthodontic services. Deductible - $25 deductible per person total per benefit year limited Adult & Child to Age 19 Limitations — Below is a pamaximum deductible rtial listing of some of the limitations. Please see Certificate for full list: • Oral Evaluations. L$50 imitfamily per benefit ed to two per year. The deductible does not apply to diagnostic and preventive services, emergency palliative treatment, x- rays, sealants, and orthodontic services. PICKERINGTON LOCAL SCHOOL DISTRICT SICK LEAVE TRANSFER REQUEST FORM Sick leave transfer requests (not to exceed thirty [30] days) must be submitted to both the Superintendent/Designee and the Association President for approval*. I, , do hereby request day(s) of sick leave Name of Employee (please print) # of days transfer starting with through to Month Day Year . Month Day Year This request is due to the following catastrophic personal illness, • Prophylaxis or Periodontal Maintenillness of a child and/or spouse (please explain)ance ProceI hereby certify that this request is due dure. Limited to two treatcatastrophic personal illnessments per yeillness of a child and/or spouse. Date Signature of employee making request Request for sick leave transfer for number of days.  Approved  Disapproved Superintendent/Designee Association President *Approved requests will be submitted to the Sick Leave Transfer Committee for collecting and verifying sick leave transfer days. PICKERINGTON LOCAL SCHOOL DISTRICT SICK LEAVE DONATION FORM I, hereby authorize the Treasurer’s Office to deduct Donor (please print) donated sick day(s) from my accumulated sick leave balance and to credit sick leave day(s) to # of days . Employee Name (please print) Donor’s Signature Date Donations from a bargaining unit member must be ar, singly or in combination. • Fluoride treatments. Limited to two per year for children up to age 19. • X-rays. Limitunits ed to one set of full-mouth x-rays or its equivalent once every five years. Periapical x-rays are limited to 4 films per year. • Bitewing X-rays. Limited to one set of up to 4 films twice per year to age 19 and once per year thereafter. • Sealants. Limited to children under 16 years of age for permanent unrestored first and second molars. Treatment is limited to two applications per toothone per lifetime.