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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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2014 PCIP Benefits Summary
This piece provides an overview of PCIP plan benefits for 2014.

2014 PCIP Brochure
This brochure describes the benefits, exclusions, limitations and maximums of the Pre-Existing Condition Insurance Plan after January 1, 2014.

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

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

2013 PCIP Brochure
This brochure describes the benefits, exclusions, limitations and maximums of the Pre-Existing Condition Insurance Plan after June 14, 2013.

January - June 2013 PCIP Brochure
This brochure describes the benefits, exclusions, limitations and maximums of the Pre-Existing Condition Insurance Plan before June 14, 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.


Click to download plan materials Click here for information on prescriptions Click here for provider search Click here for frequently asked questions

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