Documents & Forms

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UC Blue & Gold HMO

2023

Comprehensive and easy-to-use benefits available to University of California Health Net members
UC Blue and Gold 2023 Evidence of Coverage [PDF]
UC Blue and Gold 2023 Summary of Benefits & Coverage [PDF]

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]
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]
Navitus 2023 Formulary [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]

2022

2022 Navitus Maintenance Drug Program and UC Medical Center Pharmacies [PDF]
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]

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]