SAG-AFTRA Health Benefits

Plan I

Download a copy of the SAG-AFTRA Health Plan 2017 Benefits Summary.

The minimum earnings requirement for Plan I eligibility is $33,000 in covered earnings in your base earnings period.

Benefits Summary

- Hospital

Calendar Year Deductible

The Industry Health Network ‐ $150/person; $300/family

BlueCard PPO/Beacon Health Options ‐ $250/person; $500/family

Not covered

Inpatient (Room and Board and Ancillary Services)

90% after $100 copay

Not covered*

Outpatient Surgery

90% after $100 copay

Not covered

Emergency Room

90% after $100 copay; emergency room copay is waived if immediately confined

Not covered*

Coinsurance Out‐of‐Pocket Limit

$1,750/person; $3,500/family

Not covered

- Medical

Calendar Year Deductible

The Industry Health Network ‐ None

BlueCard PPO/Beacon Health Options ‐ $250/person; $500/family

$500/person; $1,000/family

Office Visit

No deductible; 100% after $25 copay

70%

Surgeon

90%

70%

X‐ray and Lab

90%

70%

Therapy (Occupational, Osteopathic, Physical, Speech, Vision)

90%

70%

Maternity Care ‐ Prenatal Visits

No deductible; 100%

70%

Maternity Care ‐ Delivery

90%

70%

Routine Physical Exam

No deductible; 100%

70%

Routine Child Exam

No deductible; 100%

70%

Routine Mammogram/Pap

No deductible; 100%

70%

Hearing Aids

90% up to a maximum payment of $1,500 per device; one device per ear per three‐year period

70% up to a maximum payment of $1,500 per device; one device per ear per three‐year period

Coinsurance Out‐of‐Pocket Limit

$1,000/person; $2,000/family

$2,500/person; $5,000/family

- Overall Out‐of‐Pocket Maximum

Hospital/Medical/Rx Out-of‐Pocket Maximum (includes Deductibles, Copays, Coinsurance)

$7,150/person; $14,300/family

None

- Mental Health and Substance Abuse

Beacon Health Options In‐Network Provider

Out‐of‐Network Provider

Hospital and Alternative Levels of Care*

Covered under Hospital Benefit

Not covered**

Medical

Covered under Medical Benefit

Covered under Medical Benefit

- Dental

Delta Dental PPO In‐Network Provider

Delta Premier and Out-of‐ Network Provider

Deductible

$75/person; $200/family

$75/person; $200/family

Diagnostic and Preventive Benefits

No deductible; 100%

75%

Basic Benefits

75%

75%

Major Benefits

50%

50%

Calendar Year Maximum***

$2,500

$2,500

- Vision

Vision Service Plan (VSP) In‐Network Provider

Out‐of‐Network Provider

Eye Exams

100% after $10 copay;

One Exam Per Calendar Year

80% up to a maximum

Payment of $50; One Exam Per Calendar Year

Glasses

20% discount

No benefit

Professional Services for Contact Lenses

15% discount

No benefit

- Prescription Drugs (Express Scripts)
Specialty medications must be obtained by mail through the specialty pharmacy, Accredo, beginning with the first fill. Long-term medications must be obtained by mail through the home delivery pharmacy (or any Walgreens Network pharmacy starting May 15, 2017) beginning with the third fill. Non-formulary drugs are not covered.

Retail

Mail Order

Calendar Year Deductible

$75/person; $150/family (combined with Mail Order)

$75/person; $150/family (combined with Retail)

Supply

Up to 30 day supply prescription or refill

Up to 90 day supply prescription or refill

Mental Health/Substance Abuse Medications

Covered as any other non‐contraceptive medication

Covered as any other non‐contraceptive medication

Copay

The greater of:

The greater of:

Generic

$10 or 10%

$20 or 10%; max copay is $50/prescription

Preferred Brand

$25 or 25%

$50 or 25%; max copay is $125/prescription

Non‐Preferred Brand

$40 or 40%

$100 or 40%; max copay is $300/prescription

In addition, if you receive a brand name drug when a generic exists, you will pay the difference in cost between the generic and brand name medication.

Generic prescription contraceptives are covered at 100% with no deductible or copay

In addition to the maximum copays listed above, if you receive a brand name drug when a generic exists, you will pay the difference in cost between the generic and brand name medication.

Generic prescription contraceptives are covered at 100% with no deductible or copay.

*Emergency treatment within 72 hours after an accident or within 24 hours of a sudden and serious illness will be covered at the In‐Network Level of Benefits.
**Alternative levels of care include Residential Treatment Center, Partial Hospital Program and Intensive Outpatient Program. 
***There is no dental maximum for individuals under age 19.