Documents & Forms

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UC High Option Supplement to Medicare

2023

High Option Supplement to Medicare—Navitus 2023 Vaccine Coverage [PDF]
High Option Supplement to Medicare 2023 Benefit Booklet [PDF]
High Option Supplement to Medicare 2023 Medical Plan Benefits Summary [PDF]
High Option Supplement to Medicare—Navitus 2023 Annual Notice of Changes [PDF]
High Option Supplement to Medicare—Navitus 2023 Evidence of Coverage [PDF]
High Option Supplement to Medicare—Navitus 2023 Medicare Part D Formulary [PDF]
High Option Supplement to Medicare—Navitus MedicareRx 2023 Summary of Benefits [PDF]

2024

High Option Supplement to Medicare 2024 Benefit Booklet [PDF]
High Option Supplement to Medicare 2024 Medical Plan Benefits Summary—English [PDF]
High Option Supplement to Medicare 2024 Medical Plan Benefits Summary—Spanish [PDF]
High Option Supplement to Medicare—Navitus 2024 Evidence of Coverage [PDF]
High Option Supplement to Medicare—Navitus MedicareRx 2024 Summary of Benefits [PDF]

2022

High Option Supplement to Medicare 2022 Benefit Booklet [PDF]
High Option Supplement to Medicare 2022 Medical Plan Benefits Summary [PDF]
High Option Supplement to Medicare 2022 Summary of Benefits & Coverage—Spanish [PDF]

UC Blue & Gold HMO

2023

Comprehensive and easy-to-use benefits available to University of California Health Net members

Forms

Health Net forms

PPO Plans: UC Care, Health Savings Plan, CORE

2023

Core 2023 Benefits Booklet [PDF]
CORE 2023 Medical Plan Benefits Summary [PDF]
Core 2023 Prescription Drug Plan Benefits Booklet [PDF]
CORE 2023 Summary of Benefits & Coverage [PDF]
CORE 2023 Summary of Benefits & Coverage—Spanish [PDF]
Health Savings Plan 2023 Benefits Booklet [PDF]
Health Savings Plan 2023 Medical Plan Benefits Summary [PDF]
Health Savings Plan 2023 Prescription Drug Plan Benefits Booklet [PDF]
Health Savings Plan 2023 Summary of Benefits & Coverage [PDF]
Health Savings Plan 2023 Summary of Benefits & Coverage—Spanish [PDF]
Navitus 2023 Formulary [PDF]
Navitus Maintenance Drug Program and UC Medical Center Pharmacies [PDF]
UC Care 2023 Benefits Booklet [PDF]
UC Care 2023 Medical Plan Benefits Summary [PDF]
UC Care 2023 Prescription Drug Plan Benefits Booklet [PDF]
UC Care 2023 Summary of Benefits & Coverage [PDF]
UC Care 2023 Summary of Benefits & Coverage—Spanish [PDF]

2024

CORE 2024 Benefits Booklet [PDF]
CORE 2024 Medical Plan Benefits Summary—English [PDF]
CORE 2024 Medical Plan Benefits Summary—Spanish [PDF]
CORE 2024 Prescription Drug Plan Benefits Booklet [PDF]
CORE 2024 Summary of Benefits & Coverage—English [PDF]
CORE 2024 Summary of Benefits & Coverage—Spanish [PDF]
Health Savings Plan 2024 Benefits Booklet [PDF]
Health Savings Plan 2024 Medical Plan Benefits Summary—English [PDF]
Health Savings Plan 2024 Medical Plan Benefits Summary—Spanish [PDF]
Health Savings Plan 2024 Prescription Drug Plan Benefits Booklet [PDF]
Health Savings Plan 2024 Summary of Benefits & Coverage—English [PDF]
Health Savings Plan 2024 Summary of Benefits & Coverage—Spanish [PDF]
UC Care 2024 Benefits Booklet [PDF]
UC Care 2024 Medical Plan Benefits Summary—English [PDF]
UC Care 2024 Medical Plan Benefits Summary—Spanish [PDF]
UC Care 2024 Prescription Drug Plan Benefits Booklet [PDF]
UC Care 2024 Summary of Benefits & Coverage—English [PDF]
UC Care 2024 Summary of Benefits & Coverage—Spanish [PDF]

2022

2022 PPO Open Enrollment Guide [PDF]
CORE 2022 Benefits Booklet [PDF]
CORE 2022 Medical Benefits Summary—Spanish [PDF]
CORE 2022 Medical Plan Benefits Summary [PDF]
CORE 2022 Navitus Pharmacy Member Brochure [PDF]
CORE 2022 Prescription Drug Summary Plan Description [PDF]
CORE 2022 Summary of Benefits & Coverage—English [PDF]
CORE 2022 Summary of Benefits & Coverage—Spanish [PDF]
Health Savings Plan 2022 Benefits Booklet [PDF]
Health Savings Plan 2022 Medical Benefits Summary—Spanish [PDF]
Health Savings Plan 2022 Medical Plan Benefits Summary [PDF]
Health Savings Plan 2022 Navitus Pharmacy Member Brochure [PDF]
Health Savings Plan 2022 Prescription Drug Summary Plan Description [PDF]
Health Savings Plan 2022 Summary of Benefits & Coverage—English [PDF]
Health Savings Plan 2022 Summary of Benefits & Coverage—Spanish [PDF]
UC Care 2022 Benefits Booklet [PDF]
UC Care 2022 Medical Plan Benefits Summary [PDF]
UC Care 2022 Navitus Pharmacy Member Brochure [PDF]
UC Care 2022 Prescription Drug Summary Plan Description [PDF]
UC Care 2022 Summary of Benefits & Coverage—English [PDF]
UC Care 2022 Summary of Benefits & Coverage—Spanish [PDF]

UC Medicare PPO

2023

Medicare PPO 2023 Benefit Booklet [PDF]
Medicare PPO 2023 Medical Plan Benefits Summary [PDF]
Medicare PPO—Navitus 2023 Annual Notice of Changes [PDF]
Medicare PPO—Navitus 2023 Evidence of Coverage [PDF]
Medicare PPO—Navitus 2023 Medicare Part D Formulary [PDF]
Medicare PPO—Navitus 2023 Vaccine Coverage [PDF]
Medicare PPO—Navitus MedicareRx 2023 Summary of Benefits [PDF]

2024

Medicare PPO 2024 Benefit Booklet [PDF]
Medicare PPO 2024 Medical Plan Benefits Summary—English [PDF]
Medicare PPO 2024 Medical Plan Benefits Summary—Spanish [PDF]
Medicare PPO—Navitus 2024 Evidence of Coverage [PDF]
Medicare PPO—Navitus MedicareRx 2024 Summary of Benefits [PDF]

2022

2022 PPO Open Enrollment Guide [PDF]
Medicare PPO 2022 Benefit Booklet [PDF]
Medicare PPO 2022 Medical Plan Benefits Summary [PDF]
Medicare PPO 2022 Summary of Benefits & Coverage—Spanish [PDF]

UC Medicare PPO Without Prescription Drugs

2023

Medicare PPO w/o Prescription Drugs 2023 Benefit Booklet [PDF]
Medicare PPO w/o Prescription Drugs 2023 Medical Plan Benefits Summary [PDF]

2024

Medicare PPO w/o Prescription Drugs 2024 Benefit Booklet [PDF]
Medicare PPO w/o Prescription Drugs 2024 Medical Plan Benefits Summary—English [PDF]
Medicare PPO w/o Prescription Drugs 2024 Medical Plan Benefits Summary—Spanish [PDF]

2022

Medicare PPO w/o Prescription Drugs 2022 Benefit Booklet [PDF]
Medicare PPO w/o Prescription Drugs 2022 Medical Plan Benefits Summary [PDF]
Medicare PPO w/o Prescription Drugs 2022 Summary of Benefits & Coverage—Spanish [PDF]

UC Medicare PPO health plans

2024

PPO and High Option Supplement to Medicare—Navitus MedicareRx 2024 Pharmacy Directory [PDF]

Forms

Authorization of Release of Personal and Health Information [PDF]
International Medical Claim Form [PDF]
Medical Claim Form [PDF]
Prescription Drug Claim Form [PDF]

PPO Plan Forms: UC Care, Health Savings Plan, CORE

Forms

Authorization of Release of Personal and Health Information [PDF]
International Medical Claim Form [PDF]
Medical Claim Form [PDF]
Prescription Drug Claim Form [PDF]