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Below explanation is for California plan only

left corner Blue Shield ACTIVE START
(Individual only)
(877)566-5454 Toll Free
FOR KIDS: These plans provide coverage for services that kids need most.
BENEFIT Active Start 25 or
Active Start 25 Generic Rx		 Active Start 35 or
Active Start 35 Generic Rx
Annual Deductible
(choose from 2 plans)		 None None
Annual Out-of-Pocket Max.
(includes deductible)		 $6,000 per member $7,500 per membery
Coinsurance 40% with preferred providers
50% with non-preferred providers
Office Visits $25 $35
Preventive Care Exam $25 $35
Mammogram & GYN screenings $0 + preventive care exam copayment
Inpatient Hospitalization $500/admit + 40%
Outpatient Surgery $500/admit + 40%
Lab and X-ray 40%
Emergency Room Services $100 (waived if admitted) + 40%
Maternity Not covered
Generic Rx Drugs $10 copay
Brand formulary Rx¹ $35 after $500 brand Rx deductible or
Not covered on Generic Rx Plan²		 $35 after $750 brand Rx deductible or
Not covered on Generic Rx Plan²

¹ Blue Shield pays up to $2,000 per member per year for brand name drugs. After the brand name Rx maximum has been met, covered brand name medications and supplies for diabetes will continue to be covered at the applicable prescription drug copayment. Amounts you pay for prescriptions do not count towards the out of pocket maximum. After you meet the out of pocket maximum, copays for prescriptions will continue.
² Brand-name prescription drug coverage is not offered under the Active Start Plan 25 Generic Rx or Active Start Plan 35 Generic Rx, with exception of covered drugs and supplies for diabetes. Brand and generic diabetes medications/supplies are covered, and may be subject to Prior Authorization for medical necessity.
  Download Your Blue Shield Active Start Brochure  

Apply for Blue Shield of CA Health Online
OR
Download Your Blue Shield Active Start Application

health insurance EKG

Or you can fill in this form to have your Blue Shield of CA Health Insurance brochure with pricing & application mailed to you. Further information on our plans is shown below. Or just call us Toll-free at 1-877-Look4Life (1-877-566-5454).
Customer Information
Name
E-mail
Street address
City
County
State
Zip Code
Home Phone
Work Phone
FAX
Insureds Age or DOB  
Smoker? Yes No
Person Covered
Plan wanted

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Barricks Insurance Services
13900 NW Passage #302, Marina Del Rey, CA 90292
Phone:   (310) 827-7286    |   Fax:   (310) 827-0256
Toll-Free 1-877-Look4Life  (1-877-566-5454)

©1995  Barricks Insurance Services. CA License #0383850
Licensed in AL, AR, AZ, CA, CO, CT, FL, GA, IA, IL, IN, KS, KY,
                   LA, MD, MI, MO, MS, NC, NE, NH, NM, NV, NY, OH,
                   OK, OR, PA, SC, SD, TN, TX, UT, VA, WI, WV