WKU Health Services IN NETWORK First Health OUT-OF- NETWORK First Health No copay AHP pays 100% $50 copay AHP pays 100% $50 copay AHP pays 60% - you pay 40%

IN NETWORK First Health (Greenwood Urgent Care) OUT-OF-NETWORK First Health $50 copay AHP pays 100% $50 copay AHP pays 60% - you pay 40%

WKU Health ServicesIN NETWORK First Health (QUEST at WKU) OUT-OF- NETWORK First Health No copay AHP pays 100% Some of these include: UA, Glucose, CBC, Flu, Strep, Mono, Pregnancy Test, Wet Prep Stain, prep for fungal elements on skin $50 copay AHP pays 100% Some of these include: Pap Smears, Lipid Panel, Liver Tests, Comp Metabolic Panel, Gonorrhea & Chlamydia testing $50 copay AHP pays 60% - you pay 40%

IN NETWORK (Greenview and Medical Center) First Health OUT-OF-NETWORK First Health $150 copay AHP pays 100% (pays up to $750 – you are responsible for amount over $750) $150 copay AHP pays 60% - you pay 40% (pays up to $750 – you are responsible for amount over $750) An ER visit may cost MORE…….. Doctor’s Visits and/or Laboratory and Diagnostic charges related to the medical emergency will be considered under those separate benefits.

IN NETWORK First Health OUT-OF-NETWORK First Health Hospital Expenses80% of Preferred Allowance $1800 maximum per day 60% of Usual and Customary Charges $800 maximum per day Surgery ($3000 Inpatient/Outpatient Maximum per condition) 80% of Preferred Allowance 60% of Usual and Customary Charges

WKU Health Services IN NETWORK First Health Vaccinations/Immunizations Including flu shot, Menactra, HPV, Twinrix (Hep A &B) 100% Paid No Copay 100% Paid $50 Copay Prescription Drugs ($250 maximum per policy year) $15 copay for generic $30 copay for brand name No benefits