Services

This program is administered
by the Managed Risk Medical Insurance Board (MRMIB).

PCIP Services

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What are the benefits in the PCIP?

The Summary Plan Description (SPD) booklet (PDF) summarizes the policies and coverage under PCIP.

This document replaces the Temporary SPD for the California PCIP, which was effective October 25, 2010 to February 28, 2011. This document is effective March 1, 2011. You should download an updated copy for your records or request a copy by mail.

The SPD gives you information about the scope of benefits and services under PCIP, how to obtain your PCIP benefits, and your rights and responsibilities as a PCIP Subscriber. Please read this document carefully; there are changes that affect the services you receive or how you receive them.

What Services Are Covered in PCIP?

While enrolled in the PCIP Program, coverage includes:

California Pre-Existing Condition Insurance Plan (PCIP) Medical Benefits
Type of service	Subscriber Costs		Limitations and Explanations
Type of service	In-Network	Out-of-Network	Limitations and Explanations
Annual Deductible	$1,500	$3,000	There are separate deductibles for in-network and out-of-network services.
Coinsurance	15%	50%	Coinsurance for services provided in-network is based on the Plan Allowance. Coinsurance for services provided out-of-network is 50% of the Plan Allowance plus any additional provider charges.
Annual Out-Of-Pocket Maximum	$2,500	N/A	Includes amounts paid towards in-network medical and brand name prescription drug deductibles, and any in-network copayments and coinsurance. When a Subscriber reaches the annual maximum, the PCIP pays 100% of covered services in-network for the remainder of the calendar year. There is no out-of-pocket maximum for services received out-of-network.
Preventive Care	0%	50%*	Covered services include: routine physical examination and related laboratory services, routine gynecological examination, routine mammogram, routine Pap smear, Human Papillomavirus (HPV) screening, ovarian and cervical cancer screening, cytology examinations, family planning counseling services, health education services, prostate screening, routine colonoscopies, hearing and vision examinations for children, newborn blood tests, sexually transmitted infections tests, Human Immunodeficiency Virus (HIV) testing, well baby and well child care, certain immunizations for adults and children, and disease management programs. Innetwork preventive care services are not subject to a deductible, copayment, or coinsurance. If you receive preventive care services from an out-of-network provider, you will have to pay any out-ofnetwork deductible that you have not met and then 50% of the Plan Allowance plus any additional provider charges.
Doctor Office Visit	$25	50%*	$25 copayment for in-network office visits. In-network office visits are not subject to the annual deductible, but do count towards your annual out-of-pocket maximum
Doctor Inpatient Visit	15%*	50%*	Doctor visits while you are in the hospital.
Inpatient Hospital Services	15%*	50%*	Prior authorization is required. You must contact PCIP within 48 hours of an emergency admission.
Inpatient Acute Rehabilitation	15%*	50%*	Prior authorization is required.
Outpatient Hospital Services	15%*	50%*	Prior authorization is required for certain surgical procedures.
Emergency Services	15%*	15%*	Limited to treatment of a medical emergency. The in-network deductible and coinsurance apply to emergency services received from an in-network or out-of-network provider.
Ambulance	15%*	15%*	Limited to a transport during a medical emergency. The in-network deductible, coinsurance, and out-of-pocket maximum apply to emergency services received from an in-network or out-of-network provider.
Surgery & Anesthesia	15%*	50%*	Prior authorization is required for certain surgical procedures.
Organ Transplants	15%*	50%*	Some transplants must be performed in a Center of Expertise to receive the in-network benefit. Prior authorization is required.
Blood & Blood Products	15%*	50%*
Cancer Clinical Trials	15%*	50%*	Prior authorization is required.
Outpatient Diagnostic X-ray & Laboratory Services	15%*	50%*	Prior authorization is required for certain radiological procedures.
Family Planning Services	15%*	50%*	Some birth control products are covered under the prescription drug benefit.
Pregnancy and Maternity Care	15%*	50%*	Includes prenatal care, delivery services and postpartum care.
Infusion Therapy	15%*	50%*
Physical Therapy	15%*	50%*
Occupational Therapy	15%*	50%*	Prior authorization is required.
Speech Therapy	15%*	50%*	Prior authorization is required.
Skilled Nursing Facility	15%*	50%*	Services are available only when determined to be a medically appropriate alternative plan of treatment that is cost effective. Prior authorization is required.
Home Health Care	15%*	50%*	Prior authorization is required.
Hospice Care	15%*	50%*	Prior authorization is required.
Durable Medical Equipment	15%*	50%*	Prior authorization is required for certain durable medical equipment.
Orthotics and Prosthetics	15%*	50%*
Inpatient Mental Health Care Services	15%*	50%*	Inpatient treatment of Serious Emotional Disturbances (SED) of a child and Severe Mental Illness (SMI) has no day limits. All other inpatient mental health care is limited to 10 days each calendar year. Prior authorization is required.
Outpatient Mental Health Care Services	15%*	50%*	Outpatient treatment of Serious Emotional Disturbances (SED) of a child and Severe Mental Illness (SMI) has no visit limits. All other outpatient mental health care is limited to 15 visits each calendar year.
Inpatient Alcohol and Substance Abuse Treatment	15%*	50%*	Services are covered to remove toxic substances from the system. Prior authorization is required.
Outpatient Alcohol and Substance Abuse Treatment	15%*	50%*	Limited to 20 visits each calendar year. Additional visits may be available with prior authorization.

* Annual deductible applies.

California Pre-Existing Condition Insurance Plan (PCIP) Prescription Drug Benefits
The CVS Caremark Drug Plan allows you access to retail pharmacies and provides mail and on-line prescription drug services. Refer to "Section 5. How to Get Prescription Drugs" of the Summary Plan Description Booklet to read more about the pharmacy benefit.
Prescription Drug	Subscriber Costs			Limitations and Explanations
	In-Network		Out-of-Network Pharmacy
	Pharmacy	Mail Order	Out-of-Network Pharmacy
Generic Drug Co-pay	$5	$5	50%**	No annual deductible.
Annual Brand Name Drug Deductible	$500		$500	There are separate deductibles for in-network and out-of-network pharmacies.
Preferred Brand Name Drug Copayment	$15*	$15*	50%**	In-network: After you have satisfied the annual brand name prescription drug deductible, if you choose a brand name drug for which a generic drug exists, you will pay the generic copayment plus the difference between the cost of the brand name drug and the cost of the generic drug, unless your doctor indicates medical necessity by writing "do not substitute" or "dispense as written" on the prescription order or by requesting and receiving prior authorization from PCIP. Out-of-network: See note below.
Non-Preferred Brand Name Drug Copayment	$30*	$30*	50%**
Specialty Drugs	N/A	$30*	N/A	Specialty drugs require prior authorization..
Maximum Supply	30 days	90 days	30 days

* The annual brand name prescription drug deductible applies.
** Subscribers pay the full cost of all drugs up front at an out-of-network pharmacy. The PCIP reimburses the Subscriber 50% of the charges for the generic or brand name prescription drug after the Subscriber submits a claim and, for brand name drugs, has satisfied the out-of-network brand name drug deductible.