Frequently Asked Questions

Eligibility

Premiums

  • Can I pay for the whole year in advance?

    Yes. The minimum payment is for one quarter (3 months). You can pay in advance for up to four quarters of your current eligibility period.

  • Are the premiums going to change every year?

    Like all Plan rules, premium amounts are subject to review by the Trustees on an ongoing basis. However, unlike COBRA premiums, which are required under federal law to be adjusted every year, the amount of premium for the earned coverage is determined solely by the Trustees, based on the financial condition of the Plan.

  • When is my premium due?

    Your premium is due by the 1st day of each calendar quarter for Earned Eligibility coverage, or by the 1st day of the month for Senior Performers or Surviving Dependent benefits. For example, the payment for the 1st quarter of the calendar year (January through March) is due on January 1. There is a 15-day grace period. Plan coverage will not be extended until your payment is processed. You are encouraged to submit your premium prior to the due date to allow processing time and avoid any interruption in your coverage. The due date applies even when traveling. The grace period is for unforeseen circumstances.

  • What if I don't receive payment information in the mail?

    If you are eligible and do not receive payment information in the mail by the 15th of the month before the start of the calendar quarter (for example, by December 15 for the first calendar quarter the following January), you should contact us at (800) 777-4013. You can also pay your premium online by logging in to your Benefits Manager or making a one-time payment. Please note, you will not receive quarterly payment coupons if you are enrolled in automatic payments.

    To ensure that you receive all quarterly billing statements and other important Plan information, be sure to keep your contact information, including your mailing address and email address, current.

  • How can I change my premium rate?

    Your premium rate is based on the number of dependents covered under the Plan. You may enroll/dis-enroll your dependents by logging in to your Benefits Manager during your Open Enrollment Period or by submitting your completed New Dependent Form to the Plan.

  • Can I dis-enroll as a participant but elect coverage for a dependent?

    In some cases, your dependents may be entitled to enroll in the program even if you do not elect coverage. Call us at (800) 777-4013 for more information.

  • Once I make the election for dependent coverage and submit the premium, can I make any changes?

    You can make multiple changes during your Open Enrollment Period regardless of whether the payment is made or not. The only restriction is that once payment is made you can no longer make changes online. Additional changes must be made using the New Dependent Form. You can also add dependents by logging in to your Benefits Manager

  • What are the premium rates?

    Please see Premiums section for current premium rates. 

  • How do I submit my premium payment?

    You can pay your premium in any of the following ways:

    1. Automatic payments. Sign up in your Benefits Manager, and your premium will be deducted from the checking or savings account you designate.
    2. One-time payment using your credit/debit card or check. You can do this in your Benefits Manager, or simply visit the premium payments page.
    3. Pay by phone at (800) 777‐4013 using a credit/debit card.
    4. Send your check, money order or cashier’s check from a U.S. bank payable to SAG-AFTRA Health Plan, P.O. Box 30110, Los Angeles, CA 90030-0110. Your payment must be received by the due date.
  • What are enrolled and dis-enrolled dependents?

    Enrolled dependent(s) are qualified family members the participant has chosen to cover for a specific eligibility period. Once the premium is received the participant and their dependent(s) will have health coverage. Dis-enrolled dependent(s) are individuals the participant chose not to cover for a specific eligibility period. Dis-enrolled dependents are not eligible for health coverage or COBRA. Dependents may only be enrolled or dis-enrolled during the participant's open enrollment period or a life event occurs.

  • How can I add a new dependent during Open Enrollment?

    Log in to your Benefits Manager to enroll new dependents or submit a New Dependent Form and all required documents to consider your dependent(s) as qualified. Examples are a recorded marriage certificate for a spouse or a recorded birth certificate for your dependent child. If adding the dependent changes your tier rate, we will send you a new billing statement for the difference in the new premiums

  • Can I add dependent(s) outside of my Open Enrollment Period?

    Yes. You may make dependent enrollment changes outside of the Open Enrollment Period if you experience a life event that results in a change in family status.

    If one of these events should occur, you will be permitted to change your dependent's enrollment status and change your premium tier (if applicable) based on the addition or loss of that dependent. A written request must be submitted to the Plan within 60 days from the date that the life event occurred.

  • Can I dis-enroll my dependent(s) outside of my Open Enrollment Period?

    Yes. If you are dis-enrolling a dependent due to divorce or death, you are required to submit a copy of the final judgment of divorce, or recorded death certificate to the Plan. In the event of divorce, you must notify the Plan within 60 days of the date of your divorce in order for the dependent to receive individual COBRA rights.

  • If I dis-enroll my dependents while on earned coverage, what will happen if I qualify for the senior performers benefit?

    You will have the opportunity to make changes to your enrolled dependents if and when you qualify for the senior performers benefit.

  • If I have coverage with another entertainment industry plan, will the special coordination of benefits rules still apply?

    Yes. The current entertainment industry coordination of benefits rules apply to all tier levels. If you qualify for coverage in the SAG-AFTRA Health Plan and another entertainment industry plan, you should contact us and your other carrier for their coordination of benefits rules.

    If your coverage in the SAG-AFTRA Health Plan is terminated because you did not pay your premium and this coverage would have been primary to another entertainment plan, coverage for you and/or your dependents under the other plan may be reduced or eliminated. You should contact your other plan for further information about how your coverage may be affected should you choose to let your coverage under this Plan lapse or choose not to enroll your dependents.

  • What happens if I am late with my premium payment?

    If your payment is not received by the due date, your earned coverage will be terminated and you will not be eligible for coverage until your next benefit period, provided you re-qualify and meet the minimum earnings requirement. You cannot enroll in the COBRA Program.

    The Plan allows one late payment waiver per Benefit Period with a maximum of two late payment waivers per lifetime for earned eligibility. If your coverage is terminated because your payment was not received by the due date you can reinstate your coverage by using a late payment waiver. Senior performers and dependents covered under the surviving dependent benefit are eligible for one late payment waiver per benefit period. Participants may use a late payment waiver up to the last day of the quarter for which a payment is due.

Benefits

  • Where can I search the Anthem/Blue Card PPO network to see if my CIGNA physician is part of the new plan?

    You may search the network provider directory to see if your CIGNA physician is in-network with Anthem/Blue Card PPO.

  • Do I have to switch from CIGNA to the Anthem/Blue Card PPO network? I want to keep my current doctor.

    There is a 96% overlap between the Anthem and CIGNA in-network providers currently used by SAG and AFTRA participants. However, it is possible that some AFTRA participants transitioning to the SAG-AFTRA Health Plan may find their provider is not in the network. You may seek Anthem's assistance with finding a new provider. To find out if your provider is in the Anthem network, search here.

  • My CIGNA provider/doctor is not part of the Anthem/Blue Card PPO network. Can I continue seeing him/her after January 1, 2017?

    Anthem has a ‘transition of care’ program for individuals who are currently undergoing a course of treatment for a serious condition and whose provider is not in the network. If approved, a participant can continue seeing their current provider until treatment is complete, and it is safe to transition to a new provider. Generally speaking eligibility includes:
    1. If you are in an active course of treatment for an acute or serious chronic condition.
    2. If you are pregnant, regardless of trimester.
    3. If you have a terminal illness.
    4. If you have a newborn child between the ages of birth and 36 months, completion of covered services may be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider.
    5. If you have an authorized surgery or other procedure scheduled to occur within 180 days of the effective date of coverage for yourself or a newly covered enrollee.

  • How do I apply for Anthem's transition of care program?

    If you are currently undergoing an active course of treatment for a serious chronic or acute condition and would like to continue seeing your CIGNA provider under the new plan, please call us at (800) 777-4013, ext. 2119. We will take your information and a representative from Anthem will contact you.

    You will also need to fill out the Anthem Transition of Care application to the best of your ability, prior to your call with the Anthem representative.  You will not have an Anthem Blue Cross ID #; please leave that section blank.

  • Are my Plan benefits guaranteed?

    No. The benefits and coverage provided under the Plan are not contractual benefits. The benefits may be reduced, modified or discontinued by action of the Trustees at any time. Your health plan benefits will never vest.

  • I think you should have paid more money on my claim. How do I appeal this claim?

    You must request reconsideration of a fully or partially denied claim within 180 days of the denial of the claim. The request must be in writing, submitted to the Chief Executive Officer and accompanied by a statement giving the reasons the denial is believed to be incorrect.

  • Are benefits paid to my doctor directly?

    When you use a network provider, benefits are automatically paid directly to the provider of service. If you use a non-network provider, the Plan must have your written authorization to pay the provider directly.

  • Does the Plan cover birth control pills?

    Yes. Birth control pills are covered under the prescription drug plan. In addition, diaphragms, Norplant, IUD's and Depo-Provera are also covered.

  • My doctor recommended that I see a nutritionist. Will the Plan cover this service?

    The Plan will cover nutritional counseling for certain chronic illnesses. Benefits are limited to one initial and two follow-up visits and are only covered if the provider is a Registered Dietitian (R.D.). There is no coverage for weight loss programs.

  • I really don't like wearing glasses and I can't wear contacts. Will the Plan pay for surgery to correct my vision?

    No. Any surgery performed to correct a refractive error, such as LASIK, is not covered under the Plan. However, Vision Service Plan (VSP), the Plan's vision program provider offers discounts on laser vision surgery to Plan I participants.

  • When do I need a pre-authorization for any of the Plan benefits?

    Pre-authorizations are required for eyelid, breast and nasal surgeries because these procedures often fall under the cosmetic exclusion. Pre-authorizations are also required for all transplant surgeries, bariatric surgeries, gender reassignment surgeries, outpatient private duty nursing and sleep studies.

    Most non-elective surgeries do not require pre-authorizations. However, it is always best to contact the Plan at least two weeks prior to your proposed surgery.

  • Can I make SAG-AFTRA Health Plan my primary insurance carrier?

    You cannot elect which plan you want as your primary plan. The determination of which plan pays first is based on NAIC (National Association of Insurance Commissioners) guidelines and specific plan rules.

  • Am I covered by the Plan when I travel to another country?

    Yes. Claims incurred in foreign countries are covered. If possible, call (800) 810-BLUE to find out what providers are in the BlueCard network and show the provider your health care ID Card. The provider may or may not file the claim for you. If you have to pay for services upfront, submit itemized bills to the Plan in English, if possible. Dental claims should be sent to Delta Dental. Pharmacy claims should be sent to Express Scripts.

  • If I am injured on the set, will the Plan pay for my medical expenses?

    Occupational injuries or illnesses are normally covered under Workers Compensation Insurance. On-the-job injuries or illnesses are not covered by the Plan. If you work for a loan-out company, you should make sure that your employer covers you under their Workers Compensation policy.

  • How are my claims paid if I have other coverage (e.g. Equity)?

    The SAG-AFTRA Health Plan will coordinate benefits with other plans in which you have coverage. If you are entitled to primary coverage with another entertainment industry health plan but choose not to pay the premium required for that coverage, the SAG-AFTRA Health Plan will continue to consider your claims as secondary. 

  • Why am I asked for information about my coverage with other plans?

    The SAG-AFTRA Health Plan will coordinate benefits with other plans in which you have coverage. Before we can process your claim, Plan rules specify that we must determine which plan should pay first and which plan should pay second.

  • My family and I have primary coverage through an HMO but don't like our choice of doctors. Can we just use the doctors under the SAG-AFTRA Health Plan?

    It is extremely important that you use your HMO when it is your primary plan. If you do not, your benefits under the SAG-AFTRA Health Plan are reduced by 80% and you will have much higher out-of-pocket expenses.

  • Will the Plan cover 100% of all my bills?

    The Board of Trustees has designed a comprehensive program of Plan benefits for you and your eligible dependents. However, not all services you receive are covered by the Plan. For covered services, you will be responsible for deductibles, co-payments and co-insurance amounts. You may also be responsible for amounts that exceed the Plan's allowance. If your doctor performs services that the Plan does not cover, you are responsible for the entire bill. It is not the intent of the Plan to dictate what type of treatment is appropriate for a patient, nor do we wish to imply that a specific treatment is not beneficial to your condition, but rather that, benefits can only be extended within the provisions and limitations of the Plan.

  • Why am I asked for accidental injury information on certain claims?

    If a claim has an accident or injury diagnosis, there may be another plan or entity which should provide benefits. If the injury occurred at work, Workers Compensation would cover the benefits. If a third party is liable for the accident, they would be responsible for the benefits. In all of these cases, we need information from you to determine how your medical expenses should be paid.

  • Does the Plan pay for eyeglasses?

    The Plan will only pay for the initial pair of eyeglasses or contact lenses of Plan I participants following a covered eye surgery (i.e., cataract surgery). Otherwise glasses are not covered except for the discounts available under the vision plan with Vision Service Plan (VSP).

Prescriptions

  • Do I have to use the Express Scripts Home Delivery Service?

    Any medication that requires more than two refills of a 30-day supply is considered long-term and must be ordered through Express Scripts home delivery or a participating Smart90 Walgreens Network pharmacy. Please see the prescription drugs page for more information. 
     
    The SAG-AFTRA Health Plan also requires that all specialty medications be obtained by mail through Express Scripts’ specialty pharmacy, Accredo beginning with the first fill.  

  • How do I use Express Scripts Home Delivery Service?

    • By fax from your doctor – Give your ID number to your doctor and have your doctor call (888) 327-9791 to obtain fax instructions.
    • Online – Visit www.express-scripts.com and follow the instructions to register for Express Scripts Pharmacy’s home delivery services. Once you've registered, click “Manage prescriptions” and follow the instructions.  Express Scripts will contact your doctor to transfer your current prescriptions to the home delivery pharmacy.
    • By mail – Log in to your Express Scripts online account. If you don’t have an account, register here. Once you are logged in, go to “Health and Benefits Information,” select “Print and Request Forms and Cards,” locate the mail order form and mail the form with your prescriptions to the address on the form. If you need help, contact Express Scripts. You can also request Express Scripts to mail you a form; this takes 7-10 days.

Dental

  • How do I locate a Delta Dental PPO dentist?

    Contact your current dentist's office and ask them if the dentist is already a part of the Delta Dental PPO network. To find a new dentist, call Delta Dental at (800) 427-3237 or visit the SAG-AFTRA Health Plan Delta Dental website.

  • What is the difference between a Delta Dental dentist and a Delta Dental PPO dentist?

    Three out of four dentists in the U.S. are Delta Dental dentists, and have an agreement with Delta Dental which means their fees are preapproved, they handle claims paperwork free of charge and they call Delta Dental directly with any inquiries. Because Delta Dental pays these dentists directly, you do not need to pay the entire bill and wait for reimbursement. Instead, you pay only the patient portion of the bill.

    Delta Dental PPO dentists are a select group of Delta dentists who, in addition to the above conveniences, also charge lower fees. And, when you visit a Delta Dental PPO dentist, you maximize your benefits. There are approximately 50,000 Delta Dental PPO dental offices around the U.S.

  • Where can I obtain a list of dentists?

    To see a list of Delta Dental PPO or DeltaPremier (Delta) dentists or to check if your current dentist is in network, visit the SAG-AFTRA Health Plan Delta Dental website.

    You may also request a list of Delta Dental PPO or Delta Premier dentists in your area by calling Delta Dental at (800) 427-3237. Please allow 7 to 10 business days for delivery.

  • Can I nominate my current dentist to become a Delta Dental in-network dentist?

    Yes. You may nominate your dentist for Delta Dental in-network membership by filling out a Dentist Nomination form. You may request a nomination form by calling Delta Dental at (800) 427-3237.

    The nomination process takes about 90 days. Please note, not all dentists will choose to participate. Admittance is not automatic and until your dentist is accepted into the Delta Dental network, he or she is considered an out-of-network dentist.

  • Are dental implants a covered benefit?

    Dental implants are covered under the Major Services portion of the Plan's dental benefits (which are payable at 50% and are subject to the Plan’s annual maximums and deductibles). Any additional surgical procedure or special imaging performed in connection with the placement of the implant is not covered under the dental or medical plan. The Plan strongly suggests that you ask your dentist to request a pre-treatment estimate from Delta Dental, so you know upfront what the Plan will pay and the amount for which you will be responsible.

  • How many oral exams and cleanings does the Plan allow?

    The Plan allows one oral examination every six months and two cleanings per calendar year. When services are provided by a Delta Dental PPO dentist, there is no deductible and 100% of the dentist's fee is covered. To help avoid an increased risk of periodontal complications due to hormonal changes, the Plan added an additional oral exam and cleaning for women while they are pregnant. To take advantage of this added benefit, the dentist will need to note on the claim that the patient is pregnant. Individuals receiving post-periodontal surgery maintenance from an in-network dentist are eligible for cleanings and scalings up to four times per year.

  • What is the advantage of using an in-network dentist versus a non-network dentist?

    You save money by using an in-network dentist because dentists in the Delta Dental network have agreed to charge lower fees for services. If you use a Delta Dental PPO dentist, your diagnostic and preventive services are covered at 100% with no deductible. In-network dentists file the claim forms for you and you are not required to pay the entire bill in advance. You may, however, be required to pay your portion of the covered services at the time of initial service and the dentist will bill Delta Dental for the balance.

  • What if I use a dentist who is not an in-network dentist?

    If you use an out-of-network dentist, you may be required to pay the entire bill in advance. You must file a claim form and submit it to Delta Dental. If your dentist's fees exceed the Plan's allowance, you are also responsible for the difference between the Plan's payment and the dentist's actual charges.

  • How do I file a claim form?

    All dental claim forms, including claims for services performed outside the United States, should be sent to:

    Delta Dental Plan of California
    Claims Department
    P.O. Box 997330
    Sacramento, CA 95899-7330
    (888) 335-8227

    Download a claim form here.

    Please note, if you use a Delta Dental in-network dentist, you do not need to submit a claim form.

Senior Performers

COBRA

Medicare