SAG-AFTRA Health Benefits

Plan I

For 2020, the minimum earnings requirement for Plan I eligibility is $35,020 in covered earnings in your base earnings period.

Download a copy of the 2019 Benefits Summary, effective January 1, 2019, or the 2020 Benefits Summary, effective January 1, 2020.

2020 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% of contract rate after $100 copay

Not covered*

Outpatient Surgery

90% of contract rate after $100 copay

Not covered

Emergency Room

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

Not covered*

Coinsurance Out‐of‐Pocket Limit

$2,750/person; $5,500/family Combined hospital and medical (including MHSA)

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% of contract rate after $25 copay (including Live Health Online)****

Medical: 60% of Plan's allowance
MHSA: 70% of Plan's allowance

Surgeon

90% of contract rate

60% of Plan's allowance

X‐ray and Lab

90% of contract rate

60% of Plan's allowance

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

90% of contract rate

60% of Plan's allowance

Maternity Care ‐ Prenatal Visits

No deductible; 100% of contract rate

60% of Plan's allowance

Maternity Care ‐ Delivery

90% of contract rate

60% of Plan's allowance

Routine Physical Exam

No deductible; 100% of contract rate

60% of Plan's allowance

Routine Child Exam

No deductible; 100% of contract rate

60% of Plan's allowance

Routine Mammogram/Pap

No deductible; 100% of contract rate

60% of Plan's allowance

Hearing Aids

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

60% of Plan's allowance up to a maximum payment of $1,500 per device; one device per ear per
three-year period

Coinsurance Out‐of‐Pocket Limit

$2,750/person; $5,000/family
Combined hospital and medical (including MHSA)

Medical: $5,000/person; $10,000/family
MHSA: $2,500/ person; $5,000/ family

- Overall Out‐of‐Pocket Maximum

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

$8,150/person; $16,300/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 beginning with the third fill. Non-formulary drugs are not covered.
Certain specialty medications are considered non-essential health benefits and fall outside the out-of-pocket limits. The cost of these drugs (though reimbursed by the manufacturer at no cost to you) will not be applied towards satisfying your out-of-pocket maximums. These non-essential health benefits will have variable copays. To determine if your specialty pharmacy drug is considered a non-essential health benefit, please visit the following website:

Express Scripts Participating Retail Pharmacy

Express Scripts Home Delivery (includes Specialty)

Calendar Year Deductible

$75/person; $150/family (Combined with Express Scripts Home Delivery [includes Specialty])

$75/person; $150/family (Combined with Express Scripts Participating Retail Pharmacy)

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 for Generic

The greater of:
$10 or 10%

The greater of:
$20 or 10%; max copay is $50/prescription

Copay for Preferred Brand

The greater of:
$25 or 25%

The greater of:
$50 or 25%; max copay is $125/prescription

Copay for Non‐Preferred Brand

The greater of:
$40 or 40%

The greater of:
$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.

****LiveHealth Online is for medical office visit only (not behavioral health).

^Certain specialty medications are considered non-essential health benefits and fall outside the out-of-pocket limits. The cost of these drugs (though reimbursed by the manufacturer at no cost to you) will not be applied towards satisfying your out-of-pocket maximums.

^^Mental Health and Substance Abuse (MHSA) Out-of-Network Provider services are covered at 70% of Plan's allowance for Plan I and 60% of Plan's allowance for Plan II.