Common use of Space Maintainers Clause in Contracts

Space Maintainers. Limited to once per quadrant per lifetime for children up to age 16. Includes all adjustments within six months of placement. • Palliative Emergency Treatment. Limited to twice per year. • Sedative Filling. Limited to once per tooth in any 24-month period. • Amalgam or Composite Resin Restorations (fillings). Limited to once per surface per tooth every 24 months. • Periodontal Scaling and Root Planing. Limited to once per quadrant every 24 months. • Periodontal Surgery. Limited to once per quadrant in any three years. • Crown Lengthening. Limited to once per tooth per lifetime. • Root Canal Therapy. Root canal therapy limited to one initial treatment per tooth and one retreatment per tooth – for permanent teeth only. • General Anesthesia. Covered only when used in conjunction with covered oral surgical procedures. Exclusions — Below is a partial listing of non-covered services. Please see Certificate for full list: • Experimental or investigative procedures • Cosmetic dentistry • Procedures requiring appliances or restorations to alter, restore or maintain occlusion • Harmful habit appliances • Charges for lost or stolen dentures or appliances or for a duplicate prosthetic device or appliance • Prescribed drugs, pre-medication or analgesia (includes nitrous oxide) • Charges for the extraction of immature erupting third molars and nonpathologic, asymptomatic third molars • Malignancies and neoplasms and the removal of tumors, cysts, and foreign bodies • Charges for tobacco counseling, oral hygiene instruction, dietary planning or behavior management • Treatment for temporomandibular joint disorder (TMJ) • Occlusal guards, adjustments • Hospital costs • Replacement of teeth missing prior to coverage under this Plan • Services or treatments that are not medically necessary • Charges for missed or cancelled appointments • Prosthodontic services unless specifically included under Covered Services • Orthodontic services unless specifically included under Covered Services Covered Benefits Network Non-Network Vision Examination Including dilation and refraction as needed Covered once every 12 months $20 copayment Up to $42 Prescription Lenses (Pair) • Standard plastic lenses up to 55mm; and all ranges of prescriptions Covered once every 24 months • Single Vision Lenses (pair) • Bifocal Lenses (Pair) • Trifocal Lenses (Pair) $20 copayment Up to $40 Up to $60 Up to $80 Frames • Covered one every 24 months No copayment, up to $130 retail value Up to $45 Contact Lenses (in lieu of frame and lens benefits) Covered one every 24 months • Contact Lenses (Elective) • Contact Lenses (Non-Elective) No copayment, up to $130 retail value No copayment Up to $105 Up to $210 Lens Options • UV Coating • Tint (Solid & Gradient) • Standard Scratch-Resistance • Standard Polycarbonate • Standard Progressive (Add-on to bifocal copayment) • Standard Anti-Reflective Coating • Other Add-ons and Services $15 $15 $15 $40 $65 $45 20% off retail Discounts on lens option upgrades are not available out-of-network. APPENDIX H

Space Maintainers. Limited to once per quadrant per lifetime for children up to age 16. Includes all adjustments within six months of placement. • Palliative Emergency Treatment. Limited to twice per year. • Sedative Filling. Filling Limited to once per tooth in any 24-month period. • Amalgam or Composite Resin Restorations (fillings). Limited to once per surface per tooth every 24 months. • Periodontal Scaling and Root Planing. Limited to once per quadrant every 24 months. • Periodontal Surgery. Limited to once per quadrant in any three years. • Crown Lengthening. Limited to once per tooth per lifetime. • Root Canal Therapy. Root canal therapy limited to one initial treatment per tooth and one retreatment per tooth – for permanent teeth only. • General Anesthesia. Covered only when used in conjunction with covered oral surgical procedures. Exclusions — Below is a partial listing of non-covered services. Please see Certificate for full list: • Experimental or investigative procedures • Cosmetic dentistry • Procedures requiring appliances or restorations to alter, restore or maintain occlusion • Harmful habit appliances • Charges for lost or stolen dentures or appliances or for a duplicate prosthetic device or appliance • Prescribed drugs, pre-medication or analgesia (includes nitrous oxide) • Charges for the extraction of immature erupting third molars and nonpathologic, asymptomatic third molars • Malignancies and neoplasms and the removal of tumors, cysts, and foreign bodies • Charges for tobacco counseling, oral hygiene instruction, dietary planning or behavior management • Treatment for temporomandibular joint disorder (TMJ) • Occlusal guards, adjustments • Hospital costs • Replacement of teeth missing prior to coverage under this Plan • Services or treatments that are not medically necessary • Charges for missed or cancelled appointments • Prosthodontic services unless specifically included under Covered Services • Orthodontic services unless specifically included under Covered Services Benefit Summary – Vision Covered Benefits Network Non-Network Vision Examination Including dilation and refraction as needed Covered once every 12 months $20 copayment Up to $42 Prescription Lenses (Pair) • Standard plastic lenses up to 55mm; and all ranges of prescriptions Covered once every 24 months • Single Vision Lenses (pair) • Bifocal Lenses (Pair) • Trifocal Lenses (Pair) $20 copayment Up to $40 Up to $60 Up to $80 Frames • Covered one every 24 months No copayment, up to $130 retail value Up to $45 Contact Lenses (in lieu of frame and lens benefits) Covered one every 24 months • Contact Lenses (Elective) • Contact Lenses (Non-Elective) No copayment, up to $130 retail value No copayment Up to $105 Up to $210 Lens Options • UV Coating • Tint (Solid & Gradient) • Standard Scratch-Resistance • Standard Polycarbonate • Standard Progressive (Add-on to bifocal copayment) • Standard Anti-Reflective Coating • Other Add-ons and Services $15 $15 $15 $40 $65 $45 20% off retail Discounts on lens option upgrades are not available out-of-network. APPENDIX HWellness Beginning with the 2013/2014 contract year, the district’s existing voluntary wellness program will be expanded. The wellness program will consist of a combination of activities that are designed to increase awareness, assess risk, educate and promote voluntary behavior change to improve the health of an individual. The district’s objective is to encourage modifications of member health status and enhance personal well-being and productivity, with a goal of preventing injury and illness. The program will include the following provisions: