University of California Human Resources and Benefits

Health Net
Log in; then select "Get things done" and then "Get forms."

Use one of the claim forms below to claim maintenance drug copay adjustments.

Mail the form to:

Health Net, Attn: Pharmacy
P.O. Box 9103
Van Nuys, CA 91409-9103

Delta Dental and PMI
Use only for non-Delta dentist.

Short-term & Supplemental Disability
Contact your local Benefits Office for Forms and assistance

Basic, Supplemental, Dependent Life
Contact your local Benefits Office for Forms and assistance

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University of California - Human Resources and Benefits
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