SAG-AFTRA Health Benefits

Plan II

For 2020, the minimum earnings requirement for Plan II eligibility is $18,040 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 ‐ $500/person; $1,000/family

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 ‐ $500/person; $1,000 family

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

Office Visit

No deductible; 100% of contract rate after $25 copay (including LiveHealth Online)****

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)^

$8,150/person; $16,300/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

Eye Exams, Glasses, Professional Services for Contact Lenses

Not covered

Not covered

- 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

Retail

Mail Order

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 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.