Pre-Existing Condition Insurance Plan (PCIP) Banner

Frequently Asked Questions - Benefits

Do I have to choose a primary care provider?

No, you are not required, but are encouraged to choose a Primary Care Provider. A close doctor-to-patient relationship is important to ensure the best medical care. We highly recommend each Subscriber select a primary care provider at the time of enrollment. This decision is important because your primary care provider will:

  • Help you decide on actions to maintain and improve your total health;
  • Coordinate your medical care needs; and
  • Work with PCIP and other health care providers to request any prior authorizations you may need.

What do I have to do to receive the $50 Comprehensive Wellness Examination credit?

PCIP will give you a one-time $50 credit on a subsequent month's premium if you chose an in-network provider and receive a comprehensive wellness examination within the first three months of your effective date of coverage. This is addressed in the Summary Plan Description under "Section 1. PCIP Facts" and "Section 4. What PCIP Covers."

What is a deductible?

A deductible is a fixed amount you must pay annually for certain covered services and supplies before we start paying for them. There are separate medical and pharmacy deductibles within PCIP. When a covered service or supply is subject to a deductible only the Plan Allowance for the service or supply counts toward the deductible. Copayments and penalties are not applied to the deductible. The amount paid toward your deductible resets every January because PCIP is based on a calendar year. This is addressed in the Summary Plan Description under "Section 3.Your Cost for Covered Services."

What is coinsurance?

Coinsurance is the percentage of the Plan Allowance that you must pay for certain services. You begin paying coinsurance after you meet your annual deductible. We will base the coinsurance percentage on either the billed charge or the Plan Allowance, whichever is less.

In PCIP, you pay 15% of the Plan Allowance for in-network services. You pay 50% of the Plan Allowance for out-of-network services, plus any additional provider charges. The coinsurance percentages are shown on the PCIP and MRMIP Costs and Benefits Chart (PDF 454kb).

The following table illustrates how much you would have to pay out-of-pocket for covered medical services from an in-network provider and from an out-of-network provider, after you have met your annual deductible.

In this example, the provider charges $150 and the Plan Allowance is $100.

In-Network Provider Out-of-Network Provider
Total You Pay
Coinsurance Only
$15
Coinsurance + Additional Charge
$100
Provider's Charge
$150
$150
Plan Allowance (determined by PCIP)
$100
$100
PCIP Pays
85% of Plan Allowance:
$85
50% of Plan Allowance:
$50
Coinsurance You Pay
15% of Plan Allowance:
$15
50% of Plan Allowance:
$50
Additional Provider Charge You Pay
None:
$0
Yes:
$50

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What is the difference between a copayment and coinsurance?

Coinsurance is the percentage of the Plan Allowance that you must pay for certain services. You begin paying coinsurance after you meet your annual deductible. A copayment is a fixed amount of money you when you receive covered services such as a doctor office visit.

What is the Plan Allowance?

The "Plan Allowance" is the amount we use to calculate our payment for covered services.

Often, a provider's bill is more than the Plan Allowance. In-network providers agree to accept the Plan Allowance as full payment. You may have to pay the difference between the Plan Allowance and the provider's charges if you use an out-of-network provider.

How do I find a provider that is participating in the PCIP PPO Network?

Click on our Provider Search to find a health care provider who will meet your needs.

How do I find out if my current provider is participating in the PCIP PPO Network?

Ask your current provider if he or she is part of the PCIP PPO Network or click on our Provider Search to search for your physician. If your provider is part of the PCIP PPO Network, that provider is considered "in-network." If your provider is not part of the PCIP PPO Network, that provider is considered "out-of-network" and you will have to pay more out-of-pocket costs if you receive services from that provider.

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What if my provider is not participating in the PCIP PPO Network?

You may see any health care provider in or out of the PCIP PPO Network for covered health care services. If you choose to see a health care provider who is not participating in the network, you will have to pay more out-of-pocket costs, as outlined on the PCIP and MRMIP Costs and Benefits Chart (PDF 454kb). This is addressed in the Summary Plan Description under "Section 1. PCIP Facts."

Are emergency services covered if the provider is out-of-network?

Emergency services are covered at the in-network deductible and coinsurance if a true emergency exists and you received services from an in-network or out-of-network provider. If you go to the emergency room for services that are not considered emergency, you may have to pay the out-of-network deductible and/or coinsurance.

What is considered an emergency?

An emergency is a medical or psychiatric condition, including active labor or severe pain, which, if not immediately treated, could:

  • Place your health in serious jeopardy.
  • Cause serious impairment to your bodily functions.
  • Cause serious dysfunction of any of your bodily organs or parts.

Examples include:

  • Severe pain;
  • Broken bones;
  • Chest pain;
  • Severe burns;
  • Fainting;
  • Drug overdose;
  • Paralysis;
  • Severe cuts that won't stop bleeding;
  • Psychiatric emergency conditions.

This is addressed in the Summary Plan Description under "Section 4. What PCIP Covers."

What happens if I am injured or become ill while I am outside of California?

Seek emergency treatment at an urgent care center or a hospital emergency room. If you are traveling outside of California, you can print a temporary identification card from the myPCIP website that you can use to obtain urgent or emergency health care services while you are traveling. Ask the provider to bill PCIP for your service.

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How are Out-of-State Claims paid?

If you receive covered services outside the state of California, ask the provider to bill PCIP. If the provider will not bill PCIP, you will have to submit the claim. Send a completed claim form, an itemized bill, and your receipts (or other documents showing proof of payment) to:

California PCIP Claims
P.O. Box 60608
King of Prussia, PA 19406-0608

You may obtain claim forms, claim filing advice, and other information about PCIP benefits on the myPCIP website or by contacting PCIP Customer Service at 1-877-629-1500 (1-800-908-9164 TTY/TDD), Monday through Friday, 6 a.m. to 6 p.m.

What is the Maximum Out-of-Pocket Amount?

Your annual out-of-pocket maximum when you use in-network providers is $2,500. Once you reach the out-of-pocket maximum for amounts paid towards in-network providers, PCIP will pay 100% of your in-network medical and prescription drug services. There is no out-of-pocket maximum for out-of-network services.

What expenses count towards the Annual Out-of-Pocket Maximum?

The following count towards your out-of-pocket maximum when using in-network providers:

  • The annual deductible of $1,500 for covered medical care services.
  • The annual deductible of $500 for brand name prescription drugs you get from an in-network pharmacy.
  • The 15% coinsurance you pay for in-network covered services.
  • The $25 copayment for office visits with in-network primary care doctors and specialists.
  • Copayments for in-network retail and mail order prescription drugs.

How can I track my claims and Out-of-Pocket Expenses?

You can track your claims and out-of-pocket expenses using the myPCIP website.

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Which services require prior authorization?

Prior authorization is required before obtaining the following services:

  • All inpatient hospital admissions;
  • Certain outpatient surgical procedures;
  • All out-of-network home health care and infusion therapies;
  • Speech and occupational therapies;
  • Certain radiological procedures;
  • Specialty drugs;
  • Organ and bone marrow or stem cell transplants;
  • Skilled nursing facility admission;
  • Hospice;
  • Certain durable medical equipment (DME);
  • Services considered experimental or investigational;
  • Alternative benefits;
  • Cancer clinical trials;
  • Phenylketonuria related formulas and special food products;
  • Emergency admissions must be authorized within 48 hours following the admission.

In-network providers will coordinate with PCIP to take care of prior authorization for you, and if you go to an out-of-network provider, he or she may be able to do so. However, whether you go to an in-network or out-of-network provider, it is your responsibility to be sure that you have prior authorization from PCIP for any services that require prior authorization. If you do not have prior authorization, you may be responsible for the full cost of any unauthorized services you receive. You should always ask your provider whether or not he or she has contacted us. Prior authorization is addressed in the Summary Plan Description under "Section 1. PCIP Facts," and "Section 4. What PCIP Covers."

Who do I call for prior authorization?

Generally, your provider will get the necessary authorization. However, you can call PCIP prior authorization staff at 1-888-860-0421 if necessary. This line is answered 24 hours a day, 7 days a week.

What can I do if PCIP doesn't authorize health care services I need?

If we make a decision to not cover services that you believe should be covered, you may appeal that decision within sixty (60) days from the date of the decision. You, your authorized representative, or your provider may request an appeal. This is addressed in the Summary Plan Description under "Section 8.Complaints and Appeal Process." Appeal Request forms are available on the myPCIP website, or by contacting PCIP at:

California PCIP Appeals
P.O. Box 60608
King of Prussia, PA 19406-0608
1-877-629-1500
1-800-908-9164 (TTY/TDD)
Fax: 1-610-491-4992
Email: pcip@hnas.com

What can I do if my claim is denied or only partially paid?

If we make a decision to deny, reduce, or modify a claim, you may appeal that decision within sixty (60) days from the date of the decision. You, your authorized representative, or your provider may request an appeal. This is addressed in the Summary Plan Description under "Section 8.Complaints and Appeal Process." Appeal Request forms are available on the myPCIP website, or by contacting PCIP at:

California PCIP Appeals
P.O. Box 60608
King of Prussia, PA 19406-0608
1-877-629-1500
1-800-908-9164 (TTY/TDD)
Fax: 1-610-491-4992
Email: pcip@hnas.com

What can I do if I do not agree with a PCIP Benefits determination?

You, your authorized representative, or your provider may request an appeal if you do not agree with a decision that was made regarding your health care benefits. There are three levels of appeals. The first level of appeal consists of a review of your case, and is conducted by PCIP medical staff. If you are unhappy with a decision made at the first level of appeal, you may request an Independent External Review (IER) of that decision. IER appeals are conducted by medical professionals working for a neutral organization. If you are unhappy with the decision made in an IER, you may request a hearing before a State of California Administrative Law Judge.

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How long does it take to resolve an appeal?

A standard appeal is resolved within 30 days after you request it. If you ask for and qualify for an expedited appeal, we will resolve the appeal within three (3) days.

What is an expedited appeal?

If the standard timeframe (30 days) for an appeal would seriously jeopardize your life or health or your ability to regain maximum function, you may request an "expedited appeal" review. Your provider will have to certify that there is an imminent and serious threat to your health including, but not limited to, severe pain or potential loss of life, limb or bodily function. We will evaluate the request for expedited review and if we determine the appeal is urgent, we will resolve the appeal within three (3) days of your request.

How do I get my prescriptions filled?

To receive prescription drugs, simply go to any in-network pharmacy and present your identification card. You will need to sign a claim form or signature log at the pharmacy and pay your appropriate copayment. Visit the CVS Caremark website to locate a participating pharmacy near you.

What if I get a prescripton filled at an out-of-network pharmacy?

If you use an out-of-network pharmacy or do not have your identification card, you will have to pay the pharmacy the full amount of the prescription. The pharmacy will need to complete the applicable section of the Direct Prescription Reimbursement Claim Form, which can be accessed through the myPCIP website. You will need to complete your sections of the form and submit the completed form, along with the receipt, to the address indicated on the form. You will be reimbursed half of the amount that would have been paid by PCIP.

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What is the difference in cost between an in-network and out-of-network pharmacy?

The following table illustrates how much you would have to pay out-of-pocket for a covered brand name prescription drug you receive from an in-network pharmacy and from an out-of-network pharmacy, after you have met your annual brand name drug deductible. In this example, the cost for the preferred brand name drug is $300.

In-Network Pharmacy Out-of-Network Pharmacy
Preferred Brand Name Drug
$300
$300
You Pay
Plan copayment
$15
100% of the cost to the pharmacy and submit a claim to PCIP for 50% of the cost.
$300
PCIP Pays
The remaining cost of the drug.
$285
50% of the drug cost.
$150
Total You Pay
$15
$150

Do I have to use a generic drug?

Yes, PCIP requires you to use generic drugs whenever available. If you choose a generic drug, you only have to pay the generic copayment. You pay much less if you use a generic drug.

What if I need a brand name drug?

PCIP has an annual brand name drug deductible. You pay all of the cost of brand name drugs until you meet this deductible. After you have met the annual deductible, you will pay the brand name drug copayment if you are prescribed a brand name drug for which there is no generic equivalent. Preferred and non-preferred brand name drugs have a different copayment amount. See the PCIP and MRMIP Costs and Benefits Chart (PDF 454kb) for more information.

If you choose a preferred or non-preferred brand name drug for which a generic equivalent exists, you will pay the generic copayment plus the difference between the cost of the preferred or non-preferred brand name drug and the cost of the generic drug. However, if your doctor states "dispense as written" or "do not substitute" on the prescription, you will have to pay only the brand name copayment.

What if I need a specialty drug?

Specialty drugs are dispensed exclusively by the CVS Caremark Specialty Pharmacy that delivers injectable medications directly to your home or office. All specialty drugs require prior authorization.

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How does the mail service prescription drug benefit work?

The mail service prescription drug program provides prescribed medications you need on a non-emergency, extended use basis. You will need to complete the Mail Order Prescription Claim Form, which can be accessed through the myPCIP website, and mail it to the address indicated on the form along with the physician's prescription.

What is Care Management?

Care Management evaluates the clinical, environmental, physical and psychological factors that may affect your ability to comply with a treatment plan or self-manage your health care. Care Management provides support so that you can comply with your treatment plan. Care Management services are available if you have a chronic illness or a behavioral health (mental health and/or substance abuse) condition. Care Management works with you to coordinate home and community-based services you need to manage your health.

What is Disease Management?

The Disease Management program works with your primary care and specialty doctors to help you get better and maintain your health. PCIP offers Disease Management programs for the following conditions: asthma, diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure and cardiovascular disease.

Who can I contact with questions about my PCIP enrollment, premium billing and statement?

If you have questions about your PCIP enrollment or your monthly PCIP premium billing statement, please call 1-877-428-5060 Monday through Friday, 8 a.m. to 8 p.m. and Saturday, 8 a.m. to 5 p.m. Persons with hearing impairments should call the California Relay Service at 711 (TTY).

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Who can I contact with questions about my PCIP claims?

If you have questions about your PCIP claims, please call 1-877-629-1500 Monday through Friday, 6 a.m. to 6 p.m. Persons with hearing impairments should call 1-800-908-9164 (TTY/TTD).

Is there anyone that can help me if I prefer to speak a language other than English?

PCIP Customer Service staff can help you find a health care provider who speaks your preferred language or who has a regular interpreter available. You do not have to use family members or friends as interpreters. If you cannot locate a health care provider who meets your language needs, you can request to have an interpreter available for medical appointments and discussions of medical information at no additional charge. Generally, you must request an interpreter at least 24 hours before your appointment.

Can I speak to a nurse over the phone?

Yes. PCIP offers a Nurse Advice Line 24-hours a day, 7 days a week to answer your health questions, provide self-care advice, and provide referrals to after-hours care when appropriate. You may call the Nurse Advice Line at 1-888-860-0421. There is no charge for this service. Services are provided in English and Spanish directly and in other languages through a telephone language line.

What Health Education Resources are available to me as a subscriber?

There are other valuable resources and services available to you as a PCIP Subscriber, including:

  • WorldDoc - a secure, health education site that helps you better manage your health. Its available 24 hours a day, 7 days a week.
  • Global Fit - offers discounts on gym memberships and weight loss programs.
  • Health Advocate - helps you find and schedule appointments with doctors and hospitals participating in the PCIP PPO Network and can assist you with questions about care for your parents and in-laws.

For more information, visit the myPCIP website.

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