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Below explanation is for California plan only

left corner Blue Shield SHIELD SAVINGS (HSA)
(877)566-5454 Toll Free
Put yourself in control, and save money while doing so.
BENEFIT SAVINGS 1800/3600¹ SAVINGS 3500¹ SAVINGS 4000/8000¹ SAVINGS 5200¹
Annual Deductible (choose from 4 low-cost plans) $1,800 per member or
$3,600 per family		 $3,500 per member or
$7,000 per family		 $4,000 per member or
$8,000 per family		 $5,200 per member or
$11,400 per family
Annual Out-of-Pocket Max. (includes deductible) $5,950 per member or
$11,900 per family		 $5,000 per member or
$10,000 per family		 $4,000 per member or
$8,000 per family		 $5,200 per member or
$11,400 per family
Office Visits $35 after deductible $0 after deductible
Preventive Care Exam $35 $0
Mammogram & GYN screenings $0 + preventive care exam copayment $0
Inpatient Hospitalization 30% after deductible $0 after deductible
Outpatient Surgery 30% after deductible $0 after deductible
Lab and X-ray 30% after deductible $0 after deductible
Emergency Room $75 (waived if admitted)
30% after deductible		 $100 (waived if admitted) after deductible $0 after deductible
Maternity Not covered
Generic Rx Drugs $10 after deductible $0 after deductible
Brand formulary Rx $35 after deductible $0 after deductible
Bridge Plan²
(Optional rider)		 n/a $1,500 per member ($3,000 maximum per family)

¹ A Health Savings Account (HSA) is a personal savings account that allows you to pay for qualified medical expenses with tax-advantaged dollars. You contribute to an HSA through pre-tax contributions. The money contributed to the account are not subject to federal income tax at the time of deposit. Funds in an HSA roll over and accumulate year after year if not spent, and all money in your HSA is owned by you. Although most consumers who enroll in an HSA-compatible health plan are eligible to open an HSA, members should consult with a financial advisor to determine if an HSA/HDHP is a good financial fit for them. Blue Shield does not offer tax advise on HSAs. HSAs are offered through financial instutions. For more information about HSAs, eligibility and the law's current provisions, consumers should ask their financial or tax adviser.
² Bridge Plan is available only at the time of enrollment, and acceptance is conditioned on approval of enrollment into an eligible health plan (Shield Savings 3500, 4000/8000, or 5200 plans). Coverage begins on the effective date of the health plan, and continues to be effective for the next 12 months. After the 12-month term has ended, the benefit will have a $0 cash value, and all premium payments for it stops. The benefit is $1,500 per member ($3,000 maximum per family), with no more than one payment per member per lifetime. The benefit is payable if you have been hospitalized for 72 consecutive hours or longer during your first year of enrollment.
  Download Your Blue Shield Shield Savings Brochure  

Apply for Blue Shield of CA Health Online
OR
Download Your Blue Shield Shield Savings 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).
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FAX
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Spouse Smoker? Yes No
People Covered
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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,
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