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Below explanation is for California plans only

left corner 2014 STANDARD BENEFITS FOR INDIVIDUALS
(877)566-5454 Toll Free
KEY BENEFITS Platinum Gold Silver
(Lower Cost Sharing
available on sliding scale)
Bronze
Copays in the Yellow Sections are NOT subject to any Deductibles
and count towards the annual out-of-pocket maximum
Benefits in Blue Sections ARE subject to Deductibles
Deductible (if any) No Deductible No Deductible $2,000 Medical Deductible $5,000 Deductible for Medical & Drugs
Preventative Care Copay No cost - at least 1 yearly visit No cost - at least 1 yearly visit
Primary Care Visit Copay $20 $30 $45 $60 - 3 visits per year
Specialty Care Visit Copay $40 $50 $65 $70
Urgent Care Visit Copay $40 $90 $60 $120
Lab Testing Copay $20 $30 $45 30%
X-Ray Copay $40 $50 $65 30%
Generic Medication Copay $5 $20 $25 $25
Brand medications may be subject to Annual Drug Deductible before you pay the copay No Deductible No Deductible $250 Deductible then pay the copay amount $50-$75 after meeting deductible
Preferred brand copay after Drug Deductible (if any) $15 $50 $50 $50
Emergency Room Copay $150 $250 $250 $300
Imaging (MRI,CT,PET Scans) $150 $250 $250 40%
High Cost & infrequent services like Hospital Care & Outpatient Surgery HMO
Outpatient Surgery - $250
Hospital - $250/day up to 5 days
PPO - 10%
HMO
Outpatient Surgery - $600
Hospital - $600/day up to 5 days
PPO - 20%
$250 30% of your plan's negotiated rate
Maximum out-of-pocket for ONE $4,000 $6,350 $6,350 $6,350
Maximum out-of-pocket for FAMILY $8,000 $12,700 $12,700 $12,700

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Barricks Insurance Services
276 N El Camino Real #6, Oceanside, CA 92058
Phone:  (760) 433-0300   |   Fax:   (760) 433-0304
Toll-Free 1-877-Look4Life  (1-877-566-5454)

©1995  Barricks Insurance Services. CA License #0383850