Below form is for California only

left corner Anthem Blue Cross INDIVIDUAL HMO      
BENEFIT Individual HMO In-Network
Annual Deductible $0
Lifetime Maximum Unlimited
Annual Out-of-Pocket Max. $3,000 per member:
Once two members each reach the maximum, the maximum is satisfied for the entire family
Doctors' Office Visits $10 copay per visit
Professional Services
(X-ray, lab, anesthesia, surgeon, etc.)		 No charge for office visit-related services
Hospital Inpatient
(Overnight Hospital Stays)		 20% of negotiated fee
Hospital Inpatient
(If You Don't Stay Overnight)		 20% of negotiated fee
Emergency Room Services 20% of negotiated fee
Maternity Office visits: $10 copay;
Inpatient/Outpatient:20% of negotiated fee
Preventive Care $10 copay for specific health maintenance services
Ambulance $50 copay, waived if admitted to the hospital
Physical & Occupational Therapy; Chiropractic Services Outpatient: $10 copay per visit
Inpatient: 20% of negotiated fee
Accupunture/Accupressure Not covered
Prescription Drugs (Anthem Blue Cross Formulary) $10 copay generic; $30 copay brand-name
after $250 brand-name prescription drug deductible
(2-member maximum); 30% of negotiated fee for
self administered injectables, except insulin
Anthem Blue Cross PPO Plan Links
HMO Saver PPO Share $500 PPO Share $1500 PPO Share $2500

  Download Your HMO Individual Brochure  

Apply for Anthem Blue Cross Health Online

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Or you can fill in this form to have your Anthem Blue Cross Individual HMO 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  
Smoker? Yes No
Spouse's Age  
Spouse Smoker? Yes No
People Covered

Have you any comments or special instructions?

 
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PPO Saver Basic PPO $1000 Basic PPO $2500 PPO Share $500 PPO Share $1000 PPO Share $1500 PPO Share $2500

PPO Share $5000 PPO Core $5000 PPO $3500 Ded. PPO $3500 HSA PPO $40 RightPlan Site Map Home Contact Us

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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)

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Licensed in AL, AR, AZ, CA, CO, CT, FL, GA, IA, IL, IN, KS, KY,
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