Plan materials

All of the forms listed below are in PDF format, which allows you to view them electronically on most computers. The Adobe Acrobat® reader is required to view and print PDF files. If you do not have the reader, click to download Adobe Acrobat for free.

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2013 PCIP Benefits Summary (2013 Spanish-language Benefits Summary)
This piece provides an overview of PCIP benefits for 2013.

2013 PCIP Brochure
This brochure describes the benefits, exclusions, limitations and maximums of the Pre-Existing Condition Insurance Plan for 2013.

Medco By Mail Order Form
PCIP enrollees use this form when mailing new prescriptions to the Medco By Mail pharmacy.

Medco Health, Allergy & Medication Questionnaire (HMQ)
Medco requests that PCIP enrollees complete this form once a year to protect against potentially harmful drug interactions and drug allergies.

Direct Reimbursement Claim Form
PCIP enrollees should use this form to submit prescription receipts when a participating pharmacy is not available.