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Medical - Compare Options

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This Medical Plan Comparison Chart includes the coverage levels for commonly used services. This comparison chart does not reflect all medical plan services, exclusions, limitations, or restrictions. It is not considered a contract or guarantee of coverage under the Plans. Refer to the Summary Plan Document located at www.oraclebenefits.com for more details on Plan provisions and limitations. Click here to find which medical plan(s) are available to you.
UHC - Medium PPO
UnitedHealthCare
UHC - Premium PPO
UnitedHealthCare
How The Plan Works
You may use any doctor or facility. You receive a higher level of benefits when you use Network providers. You are responsible for ensuring all providers are in the network.
You may use any doctor or facility. You receive a higher level of benefits when you use Network providers. You are responsible for ensuring all providers are in the network.
Coinsurance
Network: 90%
Non-Network: 70% of allowed amount 2
Network: 100%
Non-Network: 80% of allowed amount 2
Deductible
Network: $400 individual/$1,200 family
Non-Network: $800 individual/$2,400 family 5
Network: $400 individual/$1,200 family
Non-Network: $800 individual/$2,400 family 5
Deductible Type
Embedded
Embedded
Out-of-Pocket Maximum
Network: $2,000 individual/$4,000 family
Non-Network: $5,000 individual/$10,000 family 5 10
Network: $2,000 individual/$4,000 family
Non-Network: $5,000 individual/$10,000 family 5 10
Out-of-Pocket Maximum Type
Embedded
Embedded
Overall Lifetime Maximum Benefit
No maximum
No maximum
Employer Account Contribution
Not Applicable
Not Applicable
Prescription Drugs
See Pharmacy and Mail Order coverage details section below
See Pharmacy and Mail Order coverage details section below
Preventive Care
Well Baby/Child Care Visit
Network: 100%
Non-Network: 100% of allowed amount 2
Network: 100%
Non-Network: 100% of allowed amount 2
Routine Physical Exam
Network: 100%
Non-Network: 100% of allowed amount 2
Network: 100%
Non-Network: 100% of allowed amount 2
Routine Mammography
Network: 100%
Non-Network: 100% of allowed amount 2
Network: 100%
Non-Network: 100% of allowed amount 2
Preventive Care Immunizations (Adults/Children)
Network: 100%
Non-Network: 100% of allowed amount 2
Network: 100%
Non-Network: 100% of allowed amount 2
Local Pharmacy, 30-Day Supply
Generic
Network: Tier 1 - $5 copay; Limited to a 34-day supply; Deductible does not apply
Non-Network: 50% of billed charged per applicable prescription; Limited to a 34-day supply; Deductible does not apply 1 7
Network: Tier 1 - $5 copay; Limited to a 34-day supply; Deductible does not apply
Non-Network: 50% of billed charged per applicable prescription; Limited to a 34-day supply; Deductible does not apply 1 7
Preferred Brand Formulary
Network: Tier 2 - 75% ($40 minimum, $80 maximum); Limited to a 34-day supply; Deductible does not apply
Non-Network: 50% of billed charged per applicable prescription; Limited to a 34-day supply; Deductible does not apply 1 7
Network: Tier 2 - 80% ($30 minimum, $60 maximum); Limited to a 34-day supply; Deductible does not apply
Non-Network: 50% of billed charged per applicable prescription; Limited to a 34-day supply; Deductible does not apply 1 7
Non-Preferred Brand
Network: Tier 3 - 75% ($60 minimum, $120 maximum); Limited to a 34-day supply; Deductible does not apply
Non-Network: 50% of billed charged per applicable prescription; Limited to a 34-day supply; Deductible does not apply 1 7
Network: Tier 3 - 80% ($50 minimum, $100 maximum); Limited to a 34-day supply; Deductible does not apply
Non-Network: 50% of billed charged per applicable prescription; Limited to a 34-day supply; Deductible does not apply 1 7
Mail Order Pharmacy, 90-Day Supply
Generic
Network: Tier 1 - $10 copay; Limited to a 90-day supply; Deductible does not apply
Non-Network: Not covered 1 7
Network: Tier 1 - $10 copay; Limited to a 90-day supply; Deductible does not apply
Non-Network: Not covered 1 7
Preferred Brand
Network: Tier 2 - 75% ($80 minimum, $160 maximum); Limited to a 90-day supply; Deductible does not apply
Non-Network: Not covered 1 7
Network: Tier 2 - 80% ($60 minimum, $120 maximum); Limited to a 90-day supply; Deductible does not apply
Non-Network: Not covered 1 7
Non-Preferred Brand
Network: Tier 3 - 75% ($120 minimum, $240 maximum); Limited to a 90-day supply; Deductible does not apply
Non-Network: Not covered 1 7
Network: Tier 3 - 80% ($100 minimum, $200 maximum); Limited to a 90-day supply; Deductible does not apply
Non-Network: Not covered 1 7
Local Pharmacy, 90-Day Supply
Generic
Network: Tier 1 - $10 copay; Limited to a 90-day supply; Deductible does not apply
Non-Network: 50% of billed charged per applicable prescription; Limited to a 90-day supply; Deductible does not apply 1 7
Network: Tier 1 - $10 copay; Limited to a 90-day supply; Deductible does not apply
Non-Network: 50% of billed charged per applicable prescription; Limited to a 90-day supply; Deductible does not apply 1 7
Preferred Brand Formulary
Network: Tier 2 - 75% ($80 minimum, $160 maximum); Limited to a 90-day supply; Deductible does not apply
Non-Network: 50% of billed charged per applicable prescription; Limited to a 90-day supply; Deductible does not apply 1 7
Network: Tier 2 - 80% ($60 minimum, $120 maximum); Limited to a 90-day supply; Deductible does not apply
Non-Network: 50% of billed charged per applicable prescription; Limited to a 90-day supply; Deductible does not apply 1 7
Non-Preferred Brand
Network: Tier 3 - 75% ($120 minimum, $240 maximum); Limited to a 90-day supply; Deductible does not apply
Non-Network: 50% of billed charged per applicable prescription; Limited to a 90-day supply; Deductible does not apply 1 7
Network: Tier 3 - 80% ($100 minimum, $200 maximum); Limited to a 90-day supply; Deductible does not apply
Non-Network: 50% of billed charged per applicable prescription; Limited to a 90-day supply; Deductible does not apply 1 7
Outpatient Medical Services
Primary Care Office Visit
Network: $25 copay
Non-Network: 70% of allowed amount after deductible 2
Network: $20 copay
Non-Network: 80% of allowed amount after deductible 2
Specialist Office Visit
Network: $35 copay
Non-Network: 70% of allowed amount after deductible 2
Network: $30 copay
Non-Network: 80% of allowed amount after deductible 2
Telehealth Visit
Network: Available through American Well: General Physician $5 copay, Nutritionist $5 copay, Mental Health Counseling $10 copay
Non-Network: Not covered 14
Network: Available through American Well: General Physician $5 copay, Nutritionist $5 copay, Mental Health Counseling $10 copay
Non-Network: Not covered 14
Telehealth as an alternate to in-person office visits
Network: See In-Network coverage levels for in-person visits
Non-Network: See Non-Network coverage levels for in-person visits
Network: See In-Network coverage levels for in-person visits
Non-Network: See Non-Network coverage levels for in-person visits
X-ray, Radiology and Laboratory
Network: 90% after deductible
Non-Network: 70% of allowed amount after deductible. A $200 penalty is imposed if there is no prior authorization for non-network services. Penalty does not apply towards plan deductible or out of pocket maximum. 2
Network: 100% after deductible
Non-Network: 80% of allowed amount after deductible. A $200 penalty is imposed if there is no prior authorization for non-network services. Penalty does not apply towards plan deductible or out of pocket maximum. 2
Minor Surgery at a Doctor‘s Office
Network: Applicable Doctor/Specialist copay applies
Non-Network: 70% of allowed amount after deductible 2
Network: Applicable Doctor/Specialist copay applies
Non-Network: 80% of allowed amount after deductible 2
Outpatient Surgery
Network: 90% after deductible and $100 copay
Non-Network: 70% of allowed amount after deductible and $100 copay 2
Network: 100% after deductible and $100 copay
Non-Network: 80% of allowed amount after deductible and $100 copay 2
Mental Health / Substance Abuse Outpatient Services
Network: 100% for first 10 EAP visits through United Behavioral Health ; Additional sessions $25/visit
Non-Network: 90% of allowed amount after deductible 2 6
Network: 100% for first 10 EAP visits through United Behavioral Health ; Additional sessions $20/visit
Non-Network: 90% of allowed amount after deductible 2 6
Speech, Physical, Occupational Therapy
Network: $35 copay. Combined Network & Non-Network limit of 60 visits for each therapy type, per year. Medical review is needed for further visits
Non-Network: 70% of allowed amount after deductible. Combined Network & Non-Network limit of 60 visits per year for each therapy type, per year. Medical review is needed for further visits 2
Network: $30 copay. Combined Network & Non-Network limit of 60 visits for each therapy type, per year. Medical review is needed for further visits
Non-Network: 80% of allowed amount after deductible. Combined Network & Non-Network limit of 60 visits per year for each therapy type, per year. Medical review is needed for further visits 2
Inpatient Hospital Services
Precertification Requirement
Network: Provider responsibility
Non-Network: Patient responsibility. A $200 penalty applies to non-certified hospitalizations/inpatient stays. Penalty does not apply towards plan deductible or out of pocket maximum.
Network: Provider responsibility
Non-Network: Patient responsibility. A $200 penalty applies to non-certified hospitalizations/inpatient stays. Penalty does not apply towards plan deductible or out of pocket maximum.
Inpatient Admission (excludes maternity) - room & board and other charges related to a hospital stay
Network: 90% after deductible and $250 copay
Non-Network: 70% of allowed amount after deductible and $250 copay 2
Network: 100% after deductible and $250 copay
Non-Network: 80% of allowed amount after deductible and $250 copay 2
Inpatient Surgery
Network: 90% after deductible and $250 copay
Non-Network: 70% of allowed amount after deductible and $250 copay 2
Network: 100% after deductible and $250 copay
Non-Network: 80% of allowed amount after deductible and $250 copay 2
Inpatient Detoxification
Network: 90% after deductible
Non-Network: 90% of allowed amount after deductible 2
Network: 100% after deductible
Non-Network: 90% of allowed amount after deductible 2
Inpatient Substance Abuse Therapy
Network: 90% after deductible
Non-Network: 90% of allowed amount after deductible 2
Network: 100% after deductible
Non-Network: 90% of allowed amount after deductible 2
Family Planning / Maternity Care
Facility Physician Services (Mother)
Network: 90% after deductible
Non-Network: 70% of allowed amount after deductible 2 3
Network: 100% after deductible
Non-Network: 80% of allowed amount after deductible 2 3
Facility Services (Mother)
Network: 90% after deductible and $250 copay
Non-Network: 70% of allowed amount after deductible and $250 copay 2 3
Network: 100% after deductible and $250 copay
Non-Network: 80% of allowed amount , after deductible and $250 copay 2 3
Facility Physician Services (Newborn)
Network: 90% after deductible
Non-Network: 70% of allowed amount after deductible A $200 penalty is imposed if there is no prior authorization for non-network services. Penalty does not apply towards plan deductible or out of pocket maximum. 2 3
Network: 100% after deductible
Non-Network: 70% of allowed amount after deductible A $200 penalty is imposed if there is no prior authorization for non-network services. Penalty does not apply towards plan deductible or out of pocket maximum. 2 3
Facility Services (Newborn)
Network: 90% after deductible and $250 copay
Non-Network: 70% of allowed amount after deductible and $250 copay 2 11 3
Network: 100% after deductible and $250 copay
Non-Network: 80% of allowed amount after deductible and $250 copay 2 11 3
Birthing Centers
Network: 90% after deductible and $100 copay
Non-Network: 70% of allowed amount after deductible and $100 copay 2 3
Network: 100% after deductible and $100 copay
Non-Network: 80% of allowed amount after deductible and $100 copay 2 3
Midwife
Network: 90% after deductible
Non-Network: 70% of allowed amount after deductible 2 3
Network: 100% after deductible
Non-Network: 80% of allowed amount after deductible 2 3
Abortion
Coverage varies by plan guidelines/procedure setting (e.g., hospital, office visit, outpatient surgical center)
Coverage varies by plan guidelines/procedure setting (e.g., hospital, office visit, outpatient surgical center)
Birth Control Devices
Covers FDA-approved devices that cannot be purchased over the counter. Coverage varies by plan - contact UHC to verify
Covers FDA-approved devices that cannot be purchased over the counter. Coverage varies by plan - contact UHC to verify
Oral Contraceptives
Refer to Prescription Drug Benefits
Refer to Prescription Drug Benefits
Tubal Ligation
Network: 100%
Non-Network: 70% of allowed amount after deductible and applicable facility copay 1 2 9
Network: 100%
Non-Network: 80% of allowed amount after deductible and applicable facility copay 1 2 9
Vasectomy
Network: Applicable copay if performed in doctors office, otherwise 90% after deductible and applicable facility copay
Non-Network: 70% of allowed amount after deductible and applicable facility copay 2 9
Network: Applicable copay if performed in doctors office, otherwise 100% after applicable facility copay
Non-Network: 80% of allowed amount after deductible and applicable facility copay 2 9
Fertility Treatment Precertification Requirement
Fertility Solutions (FS) Network: Provider responsibility. Services must be performed in the FS Network. Non-FS services are not covered. 4
Fertility Solutions (FS) Network: Provider responsibility. Services must be performed in the FS Network. Non-FS services are not covered. 4
Coinsurance for Physician & Facility Services
Network: 70% deductible does not apply; Fertility medical services must be received by a Fertility Solutions (FS) Program Provider
Non-Network: Not covered 4
Network: 70% deductible does not apply; Fertility medical services must be received by a Fertility Solutions (FS) Program Provider
Non-Network: Not covered 4
Fertility Treatment
No lifetime maximum
(Fertility charges do not apply to out of pocket maximum)
No lifetime maximum
(Fertility charges do not apply to out of pocket maximum)
Emergency Medical Services
Emergency Room
Network: $150 copay if true emergency (waived if admitted to hospital)
Non-Network: $150 copay if true emergency (waived if admitted to hospital)
Network: $150 copay if true emergency (waived if admitted to hospital)
Non-Network: $150 copay if true emergency (waived if admitted to hospital)
Emergency Room - Non Emergency
Network: 70% after deductible
Non-Network: 70% of allowed amount after deductible 2
Network: 80% after deductible
Non-Network: 80% of allowed amount after deductible 2
Emergency - Ambulance
100% of allowed amount, deductible does not apply 2
100% of allowed amount, deductible does not apply 2
Urgent Care Visit
Network: $25 copay
Non-Network: 70% of allowed amount after deductible 2
Network: $20 copay
Non-Network: 80% of allowed amount after deductible 2
Miscellaneous Services
Chiropractic Care
Network: $35 copay. Combined Network & Non-Network limit of 20 visits per year. Medical review is needed for further visits
Non-Network: 70% of allowed amount after deductible. Combined Network & Non-Network limit of 20 visits per year. Medical review is needed for further visits 2
Network: $30 copay. Combined Network and Non-Network limit of 20 visits per year. Medical review is needed for further visits
Non-Network: 80% of allowed amount after deductible. Combined Network and Non-Network limit of 20 visits per year. Medical review is needed for further visits 2
Acupuncture
Network: 80% deductible does not apply
Non-Network: 80% of allowed amount, deductible does not apply 2
Network: 80% deductible does not apply
Non-Network: 80% of allowed amount, deductible does not apply 2
Durable Medical Equipment
Network: 90% after deductible
Non-Network: 70% of allowed amount after deductible. A $200 penalty is imposed if there is no prior authorization for non-network services. Penalty does not apply towards plan deductible or out of pocket maximum. 2
Network: 100% after deductible
Non-Network: 80% of allowed amount after deductible. A $200 penalty is imposed if there is no prior authorization for non-network services. Penalty does not apply towards plan deductible or out of pocket maximum. 2
Hearing Aids/Fitting Fees
Network: 80%, deductible does not apply, limited to a single purchase per affected ear every three years. (Includes Over the Counter (OTC) hearing aids through UnitedHealthcare Hearing)
Non-Network: 80% of allowed amount, deductible does not apply (Includes OTC hearing aids purchased outside of UnitedHealthcare Hearing) 2
Network: 80%, deductible does not apply, limited to a single purchase per affected ear every three years. (Includes Over the Counter (OTC) hearing aids through UnitedHealthcare Hearing)
Non-Network: 80% of allowed amount, deductible does not apply (Includes OTC hearing aids purchased outside of UnitedHealthcare Hearing) 2
Allergy Treatment
Network: Treatment w/office visit: Applicable Doctor/Specialist copay applies; Injections only (no office visit): 100% deductible does not apply
Non-Network: 70% of allowed amount after deductible 2
Network: Treatment w/office visit: Applicable Doctor/Specialist copay applies; Injections only (no office visit): 100% deductible does not apply
Non-Network: 80% of allowed amount after deductible 2
Allergy Testing
Network: $35 copay
Non-Network: 70% of allowed amount after deductible; If performed at lab - refer to non-preventive lab benefit 2
Network: $30 copay; If performed at lab - refer to non-preventive lab
Non-Network: 80% of allowed amount after deductible; If performed at lab - refer to non-preventive lab benefit 2
Applied Behavior Analysis (ABA) Therapy
Network: 80% after deductible
Non-Network: 80% of allowed amount after deductible 2 12 13 15
Network: 80% after deductible
Non-Network: 80% of allowed amount after deductible 2 12 13 15
Applied Behavior Analysis (ABA) Therapy Coverage Maximum
No maximum
No maximum

This Medical Plan Comparison includes the coverage levels for commonly used services. This comparison chart does not reflect all medical plan services, exclusions, limitations, or restrictions. It is not considered a contract or guarantee of coverage under the Plans. Refer to the Summary Plan Document located at www.oraclebenefits.com for more details on Plan provisions and limitations.


1 In accordance with Healthcare Reform‘s Expanded Women‘s Preventive Care Services, certain contraceptives are available at no charge. Contact your medical plan to verify coverage.
2 Allowed amount is determined by UnitedHealthcare. See Eligible Expenses under the UnitedHealthcare Medical Plans section in the Summary Plan Description.
3 If you are enrolled in one of the United Healthcare plans, you may access the Healthy Pregnancy program at the number on your id card, 1-800-411-7984 or visit www.healthy-pregnancy.com. If you are enrolled in one of the HMO plans, consult your specific HMO about any pregnancy programs they may offer.
4 United HealthCare Plan Members: Contact Fertility Solutions Program (FS) at 1-866-774-4626 or www.myoptumhealthcomplexmedical.com/gateway/public/welcome.jsp.
5 Billed charges above the allowed amount will not count towards your deductible and out-of-pocket maximum.
6 Contact United Behavioral Health (EAP) at 1-866-728-8413 or www.liveandworkwell.com.
7 United HealthCare Plan Members Prescription drugs are categorized into three tiers each with an assigned cost (e.g. copayment). Tier 1 is the lowest cost option, tier 2 is mid-range, and tier 3 is the highest cost option. Generally generic medications are classified as tier 1 however that may not always be the case. Obtain the most current tier information on www.myuhc.com or by calling UHC using the number on your ID card. Certain medications for rare and/or complex conditions are classified as Specialty Medications. These medications are subject to different dispensing processes and costs. If you are taking one more of these medications contact United Healthcare at 1-866-672-2511 for more information.
8 If you request a brand name drug with a generic alternative, you may be required to pay for the difference between generic and brand (unless the brand name was requested by your doctor).
9 If you receive these services as part of an inpatient hospital stay or as part of an outpatient hospital procedure, the applicable hospital copayment apply.
10 Out of Pocket Maximum includes deductible, coinsurance and copays. Please refer to the Plan Documents for details.
11 Separate hospitalization co-pay for the newborn may apply if the newborn is admitted for their own medical condition separate from labor and delivery. See hospital co-pays for details.
12 Coverage for physical, speech or occupational, please see those sections.
13 Progress notes required - please refer to Plan for details.
14 Telehealth benefits are available through American Well. Telehealth enables UHC eligible employees and dependents to obtain services from licensed physicians virtually. Seek care using your computer, tablet, mobile device, and telephone. Go to http://oracle.amwell.com/ for more information and/or to access services.
15 Autism services offered through Oracle‘s United Healthcare (UHC) medical plans include assessments by eligible board certified behavioral analysts, licensed mental health clinicians and therapists and comprehensive services and treatments including Applied Behavior Analysis (ABA). For more information about UHC’s autism coverage, please contact UHC at 1-866-672-2511.
16 Evidence-based medication regimens, including GLP-1s and other prescription weight-loss drugs, may be prescribed as part of a patient’s care as determined by their physician.
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