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Below explanation is for California plan only

left corner Blue Shield ESSENTIAL PLANS
(Individual only)
(877)566-5454 Toll Free
Medical, Dental, and Vision - All the Essentials in one plan
BENEFIT ESSENTIAL PLAN 1750 ESSENTIAL PLAN 3000 ESSENTIAL PLAN 4500
Annual Deductible
(choose from 3 low-cost plans)		 $1,700 per member $3,000 per member $4,500 per member
Annual Out-of-Pocket Max.
(includes deductible)		 $1,750 per member $3,000 per member $4,500 per member
Coinsurance 40% with preferred providers
Not applicable with non-preferred providers
Office Visits $40¹ copay each for first 3 visits
Preventive Care Exam $40 copay
Mammogram & GYN screenings $0 + preventive care exam copayment
Inpatient Hospitalization 0% after deductible
Outpatient Surgery 0% after deductible
Lab and X-ray 0% after deductible
Emergency Room $100 (waived if admitted)²
Maternity Not covered
Generic Rx Drugs $10 copay
Brand formulary Rx³ Not covered
Vision Services 4 Vision Exam $5 copay
Dental Services 5 Preventive & diagnostic: no charge
Minor restorative: $35-$100 (depending on procedure)

¹ After 3 visits per member per year, subsequent visits are $0 after deductible.
² Emergency room physician is 0% after deductible.
³ Brand-name drugs are not covered, with the 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.
4 With Essential Plan's vision benefit you receive an annual vision exam in California for $5.
5 The dental benefit includes coverage for preventive exams, teeth cleaning, diagnostic, and minor restorative services. Dental services are provided through the contracted dental plan administraor. Combined benefits are limited to $500 per calendar year. A three-month waiting period following the effective date of coverage is required for minor restorative services. Minor restorative services are subject to a separate $50 deductible.
  Download Your Blue Shield Essential Plan Brochure  

Apply for Blue Shield of CA Health Online
OR
Download Your Blue Shield Essential Plan 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
My Age or DOB  
Smoker? Yes No
Spouse's Age  
Spouse Smoker? Yes No
People 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,
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