SAG-AFTRA Health Benefits

Plan II^

For 2021, the minimum earnings requirement for Plan II^ eligibility is $25,950 during your 12-month Base Earnings Period.

To view 2020 Benefits Summary, download a copy of the 2020 Benefits Summary.

Note: Plan II runs out September 30, 2021

2021 Benefits Summary

- Hospital

Calendar Year Deductible

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

BlueCard PPO / Beacon Health Options:
$1,000 / person; $2,000 / family (combined w / Medical)

Not covered

Inpatient (Room and Board and Ancillary Services)

80% of contract rate after $100 copay

Not covered*

Outpatient Surgery

80% of contract rate after $100 copay

Not covered

Emergency Room

80% of contract rate after $100 copay; emergency room copay is waived if immediately confined

Not covered*

Coinsurance Out‐of‐Pocket Limit

$3,200/person; $6,400/family

Not covered

- Medical^^

Calendar Year Deductible

The Industry Health Network ‐ None

BlueCard PPO/Beacon Health Options ‐ $1,000/person; $2,000/family (combined w/ Medical)

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

Office Visit

No deductible; 100% of contract rate after $25 copay

Medical: 50% of Plan's allowance
MHSA: 60% of Plan's allowance

Surgeon

80% of contract rate

50% of Plan's allowance

X‐ray and Lab

80% of contract rate

50% of Plan's allowance

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

80% of contract rate

50% of Plan's allowance

Maternity Care:
Prenatal Visits
Delivery

No deductible; 100% of contract rate
80% of contract rate

50% of Plan's allowance
50% of Plan's allowance

Routine Physical Exam

No deductible; 100% of contract rate

50% of Plan's allowance

Routine Child Exam

No deductible; 100% of contract rate

50% of Plan's allowance

Routine Mammogram/Pap

No deductible; 100% of contract rate

50% of Plan's allowance

Hearing Aids

80% of contract rate up to a maximum payment of $1,000 per device; one device per ear per three-year period

50% of Plan's allowance up to a maximum payment of $1,000 per device; one device per ear per three-year period

Coinsurance Out‐of‐Pocket Limit

$3200/person; $6,400/family
Combined Hospital and Medical (including MHSA)

Medical: $6,000/person; $12,000/family
MHSA: $3,000/person; $6,000/family

- Overall Out‐of‐Pocket Maximum

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

$8,550/person; $17,100/family

None

- Mental Health and Substance Abuse

Hospital and Alternative Levels of Care**

Covered under the Hospital Benefit

Not covered*

Medical

Covered under the Medical Benefit

Covered under the Medical Benefit

- Dental

Calendar Year Deductible

$100/person; no family maximum

$100/person; no family maximum

Diagnostic and Preventive Benefits

No deductible; 100%

60%

Basic Benefits

60%

60%

Major Benefits

50%

50%

Calendar Year Maximum***

$1,000

$1,000

- Vision Exam Plus Plan

Eye Exams, Glasses, Professional Services for Contact Lenses

Not covered

Not covered

- Prescription Drugs (CVS Caremark)
Specialty medications must be obtained by mail through the specialty pharmacy, CVS Specialty, beginning with the first fill. Long-term medications must be obtained by mail through the home delivery pharmacy or any CVS 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. Therefore, the cost of these drugs (though reimbursed by the manufacturer at no cost to you) will not be applied toward satisfying your out-of-pocket maximums. These non-essential health benefits will have variable Copays. A list of non-essential specialty drugs will be provided once it becomes available at CVSspecialty.com/DrugList.

CVS Caremark Participating Retail Pharmacy

CVS Caremark Home Delivery

Deductible

$175/person; $350/family (combined with Mail Order)

$175/person; $350/family (combined with Retail)

Supply

Up to 30 day supply

Up to 90 day supply

Copay

The greater of:

The greater of:

Generic

$10 or 10%

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 preventive services medications, including 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.

^ Note: Plan II runs out September 30, 2021

^^ Mental Health and Substance Abuse (MHSA) Out-of-Network
Provider services are covered at 70% of Plan’s Allowance for
Active Plan (Formerly Plan I).