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Below explanation is for California plan only

left corner Blue Shield HMO PLANS
(877)566-5454 Toll Free
Simple and Easy with Rich Benefits
BENEFIT ACCESS+ HMO ACCESS+ VALUE HMO
Annual Deductible
(choose from 2 plans)		 $2,000 per member or
$4,000 per family		 $2,000 per member or
$4,000 per family
Annual Out-of-Pocket Max.
(includes deductible)		 $3,000 per member or
$6,000 per family		 $4,000 per member or
$8,000 per family
Office Visits $20 / Specialist $35 $35 / Specialist $50
Preventive Care Exam $20 $35
Mammogram & GYN screenings $0 + preventive care exam copayment
Inpatient Hospitalization $250 after deductible 40% after deductible
Outpatient Surgery $250 after deductible 40% after deductible
Lab and X-ray $20 $35
Emergency Room Services $75 (waived if admitted) $150 (waived if admitted)
Maternity¹ $250 after deductible 40% after deductible
Generic Rx Drugs $10 copay $10 copay
Brand formulary Rx $35 after $200 brand Rx deductible $35 after $400 brand Rx deductible

¹ Except for the treatment of involuntary complications of pregnancy, pregnancy/maternity benefits for a pregnancy that qualifies as a waivered condition are not available during the first six-month period beginning as of the effective date of coverage.
  Download Your Blue Shield HMO Plans Brochure  

Apply for Blue Shield of CA Health Online
OR
Download Your Blue Shield HMO Plans Application

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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,
                   LA, MD, MI, MO, MS, NC, NE, NH, NM, NV, NY, OH,
                   OK, OR, PA, SC, SD, TN, TX, UT, VA, WI, WV