City of Athens 2023 Enrollment Guide.pptx

MEDICAL INSURANCE
CARRIER: UNITEDHEALTHCARE
NETWORK: CHOICE
Please refer to the official plan documents for additional information on
coverage and exclusions.
MEDICAL BENEFITS
AXKT MOD WITH KTX RX PLAN
In-Network
Out-of-Network
Calendar Year Deductible - Individual/Family
$3,000 / $6,000
Coinsurance 80 / 20%
Out of Pocket Maximum - Individual/Family
(includes deductible, copays, and coinsurance)
Preventive Care
Primary Care Visit
Specialist Office Visit
Virtual Visits
Urgent care
Emergency Room (non-admitted)
Outpatient Lab / X-Ray
Outpatient Imaging (CT/PET scans, MRI’s)
Inpatient Facility
$7,150 / $14,300
No Charge
Less than age 19: $0 copay
All other covered persons: $10 copay
Designated Network: $40 copay
Network: $80 copay
No Charge
$25 copay
$500 copay
$40 copay
$500 copay
20% after calendar year deductible
Out-of-Network Benefits are not
available with this plan.
Outpatient Facility
PRESCRIPTION COVERAGE
20% after calendar year deductible
Retail
(up to 31 day supply)
Mail Order
(up to 90 day supply)
Tier 1 $20 copay $50 copay
Tier 2 $40 copay $100 copay
Tier 3 $75 copay $187.50 copay
COVERAGE LEVEL MONTHLY DEDUCTION 1ST & 2ND PAY PERIOD DEDUCTION
Employee Only $0.00 $0.00
Employee & Spouse $485.00 $242.50
Employee & Child(ren) $201.56 $100.78
Employee & Family $850.32 $425.16
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