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]

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 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]

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]

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

Forms

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