2020

UC
Blue & Gold
HMO

healthnet.com/uc
 DESIGNED FOR
THE UNIVERSITY
OF CALIFORNIA
The UC Blue & Gold HMO was created specifically
for UC faculty, staff and non-Medicare retirees.
Quality care and convenience are offered through
a custom Health Net provider network featuring
thousands of primary care physicians (PCPs) and
specialists and hundreds of hospitals, giving you
a wide choice of providers near where you live or
work. This includes the five renowned UC academic
medical centers and affiliated physician groups.

The UC Blue & Gold HMO plan also offers

alternative options for care, such as after-hours
virtual care at home, urgent (non-emergency)
care, and resources to keep you healthy and help
you manage ongoing conditions.

The UC Blue & Gold HMO offers the medical

coverage described in this booklet through
Health Net of California, Inc.

2 YOUR 2020 UC BLUE & GOLD HMO MEDICAL PLAN

UC BLUE & GOLD
HMO PLAN HIGHLIGHTS
With the UC Blue & Gold HMO, you get:
• $0 deductible on covered services
• No-cost or fixed copayments for services
• Low out-of-pocket maximum of $1,000 per person
or $3,000 per family, including covered medical,
behavioral health and prescription drug costs
• A PCP to coordinate your care, chosen from
among thousands of providers within the
UC Blue & Gold HMO network
• No claims to file for in-network care
• Convenient virtual and after-hours care, including:
–– Telehealth services through Teladoc. Connect with
a U.S. board-certified doctor or behavioral health
professional for a $0 copayment
–– Walk-in medical care at MinuteClinic locations in
select CVS pharmacies across the U.S.*
–– Urgent care centers that offer convenience and
lower copayments than emergency rooms

*A
 lthough the plan doesn’t normally cover routine care outside California, members may receive care at any MinuteClinic in the
country at the in-network benefit level.

YOUR 2020 UC BLUE & GOLD HMO MEDICAL PLAN 3

 COVERAGE OVERVIEW*
COVERED SERVICE YOU PAY COVERED SERVICE YOU PAY

Preventive Care (screenings and immunizations) $0 $0 for all services

except hospital stays
Maternity Care
Doctor and Specialist Office Visits for which the hospital
$20 copay copay applies
(see below for behavioral health office visits)
$250 copay per Outpatient Surgery $100 copay
admission/course
Hospitalization (medical and behavioral health)
of behavioral
health treatment Ambulance Emergency Transport
$0
(medical and behavioral health)
Visits 1–3: $0
Outpatient Behavioral Health/Substance Abuse Visits
Visits 4+: $20 copay
$5 generic;
Prescription Drugs**
24/7 Virtual Care­— $25 brand formulary;
Teladoc Visits (including behavioral health) and $0 • Retail (30-day supply) $40 non-formulary
Nurse Advice Line • Mail order or walk-up services available $10 generic;
at UC Medical Centers and CVS pharmacies $50 brand formulary;
Urgent Care $20 copay (90-day supply) $80 non-formulary
• Specialty drugs (up to a 30-day supply)
$75 copay $20
Emergency Care (medical and behavioral health)
(waived if admitted)

X-ray and Lab Procedures $0 Other Behavioral Health Outpatient Visits

• Psychological testing, outpatient electroconvulsive
$20 copay therapy, extended-length therapy sessions,
MinuteClinic
(if preventive: $0) biofeedback, applied behavior analysis, $0
methadone maintenance
$20 copay (24 visits • Structured/intensive outpatient program treatment
Chiropractic/Acupuncture combined max.
per calendar year) • Partial hospitalization/day treatment

MONTHLY PLAN COSTS

To see what you pay for coverage each month, go to UCnet > Compensation & Benefits > Health Plans > Medical Plans > UC Blue & Gold HMO.

*
T his chart is a summary of benefits only. All benefits are subject to the definitions, limitations and exclusions set forth in the Summary of Benefits included with Open Enrollment information. Employees and non-Medicare retirees are encouraged to
review it before making their final decisions. The behavioral health annual out-of-pocket maximums are combined with medical and pharmacy benefits.
**
Members are required to pay the cost difference between a brand name and a generic copayment, when the generic is available. Exceptions for medical necessity are available via prior authorization. If approved, the applicable brand copayment applies.

4 YOUR 2020 UC BLUE & GOLD HMO MEDICAL PLAN

AFTER HOURS CARE CARING FOR THE WHOLE
YOU: BEHAVIORAL HEALTH
ANYTIME, ANYWHERE The UC Blue & Gold HMO offers
behavioral health support and substance
Illness and injury can occur any time of day. While your PCP abuse treatment for you and your covered
is your go-to for most health problems, an illness may occur family members through Managed Health
after hours that requires urgent care but is not an emergency. Network, LLC (MHN), and Teladoc. This
The UC Blue & Gold HMO offers several non-emergency care includes office and virtual visits, inpatient
options that are as good as seeing your own provider, including treatment and aftercare following
video chat with a board-certified doctor, telephone advice from inpatient treatment. You can choose to
a registered nurse and local urgent care centers. access care in the way it best works for
you—in person, virtual or a combination.
For life-threatening emergencies, go to the closest emergency
room or call 911. For conditions such as coughs, sore throats,
earaches, sinus infections, pinkeye, rashes and respiratory
infections, try these resources.

TELADOC NURSE ADVICE LINE MINUTECLINIC URGENT CARE FACILITY

teladoc.com/uc
(800) 893-5597 minuteclinic.com healthnet.com/uc > Find a Doctor
(800) 835-2362

Cost: $0 Cost: $0 Cost: $20 copay Cost: $20 copay

Available: 24/7 Available: 24/7 Available: 7 days a week; hours vary Available: Varies
Speak to a U.S. board-certified doctor Speak or chat with a nurse MinuteClinics are located inside Prompt medical attention for
about non-emergency medical issues about symptoms, minor illnesses select CVS Pharmacy stores, serious conditions—but not
(cold and flu, allergies, urinary tract or injuries, chronic conditions, nationwide. Clinicians can evaluate emergencies—such as bladder
infections, etc.) via web, phone or medical tests and medications. and treat most minor conditions and ear infections, cough or flu
mobile app. (including prescribing medicine) symptoms, cuts, abdominal pain,
Behavioral Telehealth with psychiatrists, including allergies, coughs, earaches sprains, strains and joint pain.
psychologists and licensed clinical or infections, minor burns, sprains,
social workers is also available. skin conditions and infections.

YOUR 2020 UC BLUE & GOLD HMO MEDICAL PLAN 5

FIND A DOCTOR, HOSPITAL OR
URGENT CARE CENTER
The UC Blue & Gold HMO requires that, except in
the case of an emergency, all care be coordinated
by your PCP and delivered by in-network providers.

For the most up-to-date list of qualified, in-network

PCPs, specialists, urgent care facilities, hospitals
and other types of health care providers near you,
go to healthnet.com/uc:

1. Click Find a Doctor.

2. Enter your location (street address, city,
county or state).
3. Narrow your search by provider name/ID/
license number or plan/network.
4. Select a type of provider (doctors, hospital,
medical group, etc.).
5. Click Print Results to print your search results,
if needed.

Or call the UC-dedicated Health Benefit Navigators

team toll-free at (800) 539-4072, Monday through
Friday, 8:00 a.m. to 8:00 p.m. (Pacific).

6 YOUR 2020 UC BLUE & GOLD HMO MEDICAL PLAN

SUPPORTING THE HELP IS ALWAYS
AVAILABLE
HEALTH OF YOUR To find a participating MHN counselor,
psychologist or psychiatrist, go to
BODY AND MIND healthnet.com/uc and click on
behavioral health – MHN, or call
The UC Blue & Gold HMO plan partners with organizations to deliver (800) 663-9355 (TTY: 711), Monday
programs to help you get and stay physically and emotionally healthy. through Friday, 8:00 a.m. to 8:00 p.m.
To learn more, go to healthnet.com/uc. Under the Health Net Extras (Pacific).
section, select Wellness programs and discounts.
For Teladoc services, go to
The Active&Fit Direct™ program teladoc.com/uc, or call
Fitness center membership program that offers $25-a-month membership at over 10,000 (800) 835-2362.
participating fitness centers and YMCAs nationwide (plus one-time $25 enrollment fee and taxes).

Health Coaching programs

For 24/7 crisis help, call
One-on-one phone support with unlimited access to a registered dietitian or health (800) 663-9355 (TTY: 711).
educator to help you reach your goals and sustain positive change.

myStrength
Interactive, individually tailored virtual program to address depression, anxiety, stress,
substance abuse, chronic pain and sleep challenges, while also supporting physical and
spiritual aspects of the whole person.

Omada
Online personalized behavior-change program to support people at risk of developing
and those living with type 2 diabetes and other chronic conditions.

Quit For Life® tobacco cessation

One-on-one telephonic support to help you quit smoking or stop using e-cigarettes.

Start Smart for Your Baby

Support for all expecting mothers, including high-risk pregnancies.
Includes information about postpartum and new baby care.

YOUR 2020 UC BLUE & GOLD HMO MEDICAL PLAN 7

 YOUR CHECKLIST DURING AND
AFTER OPEN ENROLLMENT
See below for key choices to consider and tasks to complete during and after Open Enrollment.

During Open Enrollment: After Open Enrollment

October 31–November 26, 2019 CONTINUING MEMBERS NEW MEMBERS
ALL MEMBERS PROSPECTIVE MEMBERS □□ There are no actions you need □□ Get enough refills of any ongoing
to take. medications to last through early
□□ Compare all your UC health plan □□ Decide if the UC Blue & Gold
January 2020.
options, and make sure the UC HMO is the right plan for you.
Blue & Gold HMO is still the right □□ Check to see if your current PCP □□ Watch for new ID cards in the mail.
choice for you and your family. In December 2019, Health Net will
and behavioral health providers
send you one package in the mail
□□ Decide if enrolling in the Health are in the UC Blue & Gold
with an ID card for each covered
Care Flexible Spending Account HMO network.
family member. Continue using
(FSA) to pay for out-of-pocket □□ You must select a PCP when you your current ID card through
health care expenses (such as enroll. Go to healthnet.com/uc, December 31, 2019.
copayments) with pre-tax and click on Find a Doctor, or call
dollars is right for you. You the Health Benefit Navigators On or After January 1, 2020*
must enroll or re-enroll in the team toll-free at (800) 539-4072,
FSA every year during the Monday through Friday, 8:00 CONTINUING MEMBERS NEW MEMBERS
Open Enrollment period. a.m. to 8:00 p.m. (Pacific). If
□□ If needed, add or drop your current doctor isn’t in the
□□ Explore healthnet.com/uc, □□ If you have a new PCP, make an
which offers 24/7 access to appointment for an office visit
dependents from coverage network, you will need to select
benefit details, including to review your current health
through AYSO or UCPath. a new PCP. You can change
what’s covered and what history. Work with your former
your PCP at any time on
you pay for care. providers to transfer your medical
healthnet.com/uc or by
calling Health Net. □□ Register with Teladoc for records to your new doctor.
24/7 access to U.S. board- □□ Provide your new ID card to your
certified doctors or behavioral provider(s) and pharmacy on your
health professionals for first visit after the new year.
a $0 copayment. Go to □□ Discard your 2019 plan ID card,
teladoc.com/uc or call and only use the UC Blue & Gold
(800) 835-2362 to register HMO ID card.
so the service is ready to use
immediately when you need it.

* If there are plan changes during the year, you will receive new ID cards for use at providers and the pharmacy.
8 YOUR 2020 UC BLUE & GOLD HMO MEDICAL PLAN
In addition to the State of California nondiscrimination requirements (as described in benefit coverage documents),
Health Net of California, Inc. (Health Net) complies with applicable federal civil rights laws and does not discriminate,
exclude people or treat them differently on the basis of race, color, national origin, ancestry, religion, marital status,
gender, gender identity, sexual orientation, age, disability or sex.

Health Net: Email: [email protected] (Members) or

Provides free aids and services to people with disabilities to communicate [email protected] (Applicants)
effectively with us, such as qualified sign language interpreters and written
If your health problem is urgent, if you already filed a complaint with Health Net
information in other formats (large print, accessible electronic formats,
of California, Inc., and are not satisfied with the decision, or it has been more than
other formats).
30 days since you filed a complaint with Health Net of California, Inc., you may
Provides free language services to people whose primary language is not English, submit an Independent Medical Review/Complaint Form with the Department
such as qualified interpreters and information written in other languages. of Managed Health Care (DMHC). You may submit a complaint form by calling
the DMHC Help Desk at (888) 466-2219 (TDD: (877) 688-9891) or online at
If you need these services, contact Health Net's Customer Contact Center at dmhc.ca.gov/FileaComplaint.
(800) 539-4072 (TTY: 711).
If you believe you have been discriminated against because of race,
If you believe that Health Net has failed to provide these services or discriminated color, national origin, age, disability or sex, you can also file a civil rights
in another way based on one of the characteristics listed above, you can file a complaint with the U.S. Department of Health and Human Services, Office
grievance by calling Health Net's Customer Contact Center at the number above for Civil Rights (OCR), electronically through the OCR Complaint Portal, at
and telling them you need help filing a grievance. Health Net's Customer Contact https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
Center is available to help you file a grievance. You can also file a grievance by mail, U.S. Department of Health and Human Services, 200 Independence Avenue
fax or email at: SW, Room 509F, HHH Building, Washington, DC 20201, (800) 368-1019
(TDD: (800) 537-7697).
Health Net of California, Inc. Appeals & Grievances
P.O. Box 10348 Complaint forms are available at
Van Nuys, CA 91410-0348 http://www.hhs.gov/ocr/office/file/index.html.
Fax: (877) 831-6019

YOUR 2020 UC BLUE & GOLD HMO MEDICAL PLAN 9

 English
No-Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed
on your ID card, or call 1-800-539-4072 (TTY: 711). If you need these services, contact Health Net's Customer Contact Center at 1-800-539-4072 (TTY: 711).

Arabic
‫ةيناجم ةغللا تامدخ‬. ‫يروف مجرتم ىلع لوصحلا كنكمي‬. ‫كل ةءورقم قئاثو ىلع لوصحلا كنكميو‬. ‫ةدعاسملا ىلع لوصحلل‬، ‫ىلع انب لصتا‬
1-800-539-4072 (TTY: 711) ‫ةيوهلا ةقاطب ىلع دوجوملا مقرلا‬، ‫يراجتلا لاصتالا زكرم ىلع لصتا وأ‬

Armenian
Անվճար լեզվական ծառայություններ: Դուք կարող եք բանավոր թարգմանիչ ստանալ: Փաստաթղթերը կարող են կարդալ ձեզ համար: Օգնության համար
զանգահարեք մեզ ձեր ID քարտի վրա նշված հեռախոսահամարով կամ զանգահարեք 1-800-539-4072 (TTY: 711).

Chinese
免費語言服務。您可使用口譯員。 您可請人使用您的語言將文件內容唸給您聽，並請我們將有您 語言版本的部分文件寄給您。
如需協助，請致電您會員卡上所列的電
話號碼與我們聯絡，或致電 1-800-539-4072 (TTY: 711)。

Hindi
बिना लागत की भाषा सेवाएँ। आप एक दुभाषिया प्राप्त कर सकते हैं। आपको दस्तावेज पढ़ कर सुनाए जा सकते हैं। मदद के लिए, आपके आईडी कार्ड पर दिए गए सूचीबद्ध नंबर पर हमें कॉल करें, या
1-800-539-4072 (TTY: 711).

Hmong
Kev Pab Txhais Lus Dawb. Koj xav tau neeg txhais lus los tau. Koj xav tau neeg nyeem cov ntaub ntawv kom yog koj hom lus los tau. Xav tau kev pab, hu peb tau rau tus
xov tooj ntawm koj daim npav los yog hu 1-800-539-4072 (TTY: 711).

Japanese
無料の言語サービス。通訳をご利用いただけます。文書をお読みします。援助が必要な場合は、IDカードに記載されている番号までお電話いただくか、1-
800-539-4072 、1-800-539-4072 (TTY: 711)。

Khmer
សេវាភាសាសោយឥតគិតថ្លៃ។ អ្នកអាចទទួលបានអ្នកបកប្បផ្ទា ល់មាត់។ អ្នកអាចសាដា ប់សគអានឯកសារឱ្យអ្នក។ េ្មាប់ជំនួយ េូម ទាក់ទងសយើងខ្ញំតាមរយៈសលខទូរេពទាបែលមាន
សៅសលើកាតេមាគា ល់ ួលៃខនរបេ់អ្នក ឬ ទាក់ទងសៅមជ្ឈមណ្ឌ លទំនាក់ទំនងពាណិ ជ្ជកម្ម ថន្ករុមហញ៊ន 1-800-539-4072 (TTY: 711).។

Korean
무료 언어 서비스. 통역 서비스를 받을 수 있습니다. 귀하가 구사하는 언어로 문서의 낭독 서비스를 받으실 수 있습니다. 도움이 필요하시면 보험 ID 카드에 수록된 번호로
전화하시거나 1-800-539-4072 (TTY: 711).

Navajo
Saad Bee Áká E’eyeed T’áá Jíík’e. Ata’ halne’ígíí hólǫ́ T’áá hó hazaad k’ehjí naaltsoos hach’į’ wóltah. Shíká a’doowoł nínízingo naaltsoos bee néího’dólzinígíí bikáa’gi béésh
bee hane’í bikáá’ áajį’ hodíílnih éí doodaii’ 1-800-539-4072 (TTY: 711).

10 YOUR 2020 UC BLUE & GOLD HMO MEDICAL PLAN

Persian (Farsi)
‫ناگيار روط هب نابز تامدخ‬. ‫ديريگب یهافش مجرتم کي ديناوت یم‬. ‫دنوش تئارق امش یارب دانسا هک دينک تساوخرد ديناوت یم‬. ‫یيامنهار تفايردیارب‬، ‫ام اب‬
‫یناگرزاب سامت زکرم اب اي ديريگب سامت هدش جرد امش یياسانش تراک یور هک یا هرامش هب‬. 1-800-539-4072 (TTY: 711).

Panjabi (Punjabi)
ਬਿਨਾਂ ਕਿਸੇ ਲਾਗਤ ਤੋਂ ਭਾਸ਼ਾ ਸੇਵਾਵਾਂ। ਤੁਸੀਂ ਇੱਕ ਦੁਭਾਸ਼ਿਆ ਪ੍ਰਾਪਤ ਕਰ ਸਕਦੇ ਹੋ। ਤੁਹਾਨੂੰ ਦਸਤਾਵੇਜ਼ ਤੁਹਾਡੀ ਭਾਸ਼ਾ ਵਿੱਚ ਪੜ੍ਹ ਕੇ ਸੁਣਾਏ ਜਾ ਸਕਦੇ ਹਨ। ਮਦਦ ਲਈ, ਆਪਣੇ ਆਈਡੀ ਕਾਰਡ ਤੇ ਦਿੱਤੇ ਨੰਬਰ ਤੇ ਸਾਨੂੰ ਕਾਲ ਕਰੋ
ਜਾਂ ਕਿਰਪਾ ਕਰਕ 1-800-539-4072 (TTY: 711).

Russian
Бесплатная помощь переводчиков. Вы можете получить помощь устного переводчика. Вам могут прочитать документы. За помощью обращайтесь к нам по
телефону, приведенному на вашей идентификационной карточке участника плана. Кроме того, вы можете позвонить в 1-800-539-4072 (TTY: 711).

Spanish
Servicios de idiomas sin costo. Puede solicitar un intérprete. Puede obtener el servicio de lectura de documentos y recibir algunos en su idioma. Para obtener ayuda,
llámenos al número que figura en su tarjeta de identificación o comuníquese con el 1-800-539-4072 (TTY: 711).

Tagalog
Walang Bayad na Mga Serbisyo sa Wika. Makakakuha kayo ng isang interpreter. Makakakuha kayo ng mga dokumento na babasahin sa inyo. Para sa tulong, tawagan kami
sa nakalistang numero sa inyong ID card o tawagan ang 1-800-539-4072 (TTY: 711).

Thai
ไม่มีค่าบริการด้านภาษา คุณสามารถใช้ล่ามได้ คุณสามารถให้อ่านเอกสารให้ฟังได้ สณาหรับความช่วยเหลือ โทรหาเราตาม หมายเลขท่ีให้ไว้บนบัตรประจณาตัวของคุณ หรือ โทรหา
ศูนย์ติดต่อเชิงพาณิชย์ของ 1-800-539-4072 (TTY: 711).

Vietnamese
Các Dịch Vụ Ngôn Ngữ Miễn Phí. Quý vị có thể có một phiên dịch viên. Quý vị có thể yêu cầu được đọc cho nghe tài liệu. Để nhận trợ giúp, hãy gọi cho
chúng tôi theo số được liệt kê trên thẻ ID của quý vị hoặc gọi 1-800-539-4072 (TTY: 711).

You have access to Decision Power, myStrength, Omada and Teladoc through current enrollment with Health Net of California, Inc. (Health Net). Decision Power, myStrength, Omada
and Teladoc are not part of Health Net’s commercial medical benefit plans. They are not affiliated with Health Net’s provider network, and their services may be revised or withdrawn
without notice. These services, including clinicians, are additional resources that Health Net makes available to enrollees. The information provided is not intended as a substitute for
professional medical care. Please always follow your health care provider’s instructions.

Health Net of California, Inc., is a subsidiary of Health Net, LLC. Managed Health Network, LLC (MHN) is a subsidiary of Health Net, LLC. The MHN family of companies includes
Managed Health Network (CA) and MHN Services, LLC. Managed Health Network is a registered service mark of Managed Health Network, LLC. Health Net and Decision Power are
registered service marks of Health Net, Inc. All other identified trademarks/service marks remain the property of their respective companies. All rights reserved.

YOUR 2020 UC BLUE & GOLD HMO MEDICAL PLAN 11

CONTACT HEALTH NET
MEMBER PORTAL
healthnet.com/uc

HEALTH BENEFIT NAVIGATORS

(800) 539-4072
Monday through Friday,
8:00 a.m. to 8:00 p.m. (Pacific)

EMAIL
Askblue&[email protected]
for a response within 24 hours,
Monday through Friday

FACEBOOK
@HealthNetForUC
Offers wellness tips for the whole family

MHN CUSTOMER SERVICE TEAM

(800) 663-9355
Monday through Friday, 8:00 a.m.
to 8:00 p.m. (Pacific)