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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.

Select up to 3 plans to compare

UHC - HI EPO	UHC - EPO	UHC - Medium PPO
Kaiser Foundation Health Plan of Washington	UHC - Premium Out of Area	Kaiser Mid-Atlantic
UHC - HPHC Passport	UHC - Premium PPO	Kaiser Northern CA
UHC - HSA Medical Plan	Kaiser Atlanta	Kaiser Northwest
UHC - Medium Out of Area	Kaiser Colorado	Kaiser Southern CA

UHC - Medium PPO

UHC - Premium PPO

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.

Coinsurance

Network: 90%
Non-Network: 70% of allowed amount ⁵

Network: 100%
Non-Network: 80% of allowed amount ⁵

Deductible

Network: $400 individual/$1,200 family
Non-Network: $800 individual/$2,400 family ⁵

Deductible Type

Embedded

Out-of-Pocket Maximum

Network: $2,000 individual/$4,000 family
Non-Network: $5,000 individual/$10,000 family ¹⁰

Out-of-Pocket Maximum Type

Embedded

Overall Lifetime Maximum Benefit

No maximum

Employer Account Contribution

Not Applicable

Prescription Drugs

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

Routine Physical Exam

Network: 100%
Non-Network: 100% of allowed amount ²

Routine Mammography

Network: 100%
Non-Network: 100% of allowed amount ²

Preventive Care Immunizations (Adults/Children)

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

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

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

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

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

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.

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)

Birth Control Devices

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

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 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

RRS Network: Provider responsibility. Services must be performed by Reproductive Resource Services. Non-RRS services are not covered. ⁴

Coinsurance for Physician & Facility Services

Network: 70%; Fertility medical services must be received by Reproductive Resource Services
Non-Network: Not covered ⁴

Fertility Treatment

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)

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 billed charges

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%
Non-Network: 80% of billed charges

Durable Medical Equipment

Hearing Aids/Fitting Fees

Network: 80% 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 ² (Includes OTC hearing aids purchased outside of UnitedHealthcare Hearing)

Allergy Treatment

Network: Treatment w/office visit: Applicable Doctor/Specialist copay applies; Injections only (no office visit): 90%
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%
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 billed charges after deductible ¹² ¹³ ¹⁵

Applied Behavior Analysis (ABA) Therapy Coverage 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.

¹In 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 Amount that is typically accepted by a healthcare provider for the same or similar service in a geography.
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 Reproductive Resource Services (RRS) at 1-866-774-4626 or www.myoptumhealthcomplexmedical.com/gateway/public/welcome.jsp.
⁵ Deductible and copayment applies only when noted "after deductible" and "copay".
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 copays for items such as office visits, hospital network pharmacy and emergency room. 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.

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