Name and Type of Plan
SAG-AFTRA Health Plan
This Plan is a collectively bargained, joint-trusteed labor-management trust.
Plan’s Identification Numbers
The Employer Identification Number (EIN) assigned to the Plan by the Internal
Revenue Service is 95-6024160.
The Plan number is 501.
The Plan’s fiscal year runs from January 1 through December 31.
The administrator of the Plan is the Board of Trustees, made up of an equal number of representatives from Contributing Employers and SAG-AFTRA.
The routine administrative functions are performed by the Plan. The chief executive officer is Michael Estrada, who may be reached at the same address and telephone number as the Board of Trustees.
Names and Addresses of the Current Board of Trustees
The names of the Trustees as of the date this SPD was printed are listed on page 3. To contact the Board of Trustees, write, call or fax:
SAG-AFTRA Health Plan
P.O. Box 7830
Burbank, CA 91510-7830
Fax: (818) 953-9880
Agent for Service of Legal Process
Legal process may be served on the Trustees or the chief executive officer at:
SAG-AFTRA Health Plan
3601 West Olive Avenue
Burbank, CA 91505
P.O. Box 7830
Burbank, CA 91510-7830
Collective Bargaining Agreements
The Plan is maintained according to a number of Collective Bargaining Agreements between SAG-AFTRA and employers in the industry.
The Collective Bargaining Agreements are available on the SAG-AFTRA website: www.sagaftra.org. Or, you may request that the Plan provide you with a copy of the applicable Collective Bargaining Agreement. You will be charged a reasonable amount for copying. The agreements are available for inspection at the office of the chief executive officer.
Source of Financing
Contributions are made to the Plan by Contributing Employers according to the terms of applicable Collective Bargaining Agreements. In addition, the Plan requires Participants to pay a premium for coverage. Participants and Dependents whose eligibility under the Plan has terminated may continue coverage under COBRA, in accordance with the rules described on pages 37-43.
Plan Changes or Termination/Reservation of Rights
The benefits provided under the Plan are not guaranteed benefits for either active or retired Participants or for their Dependents. Therefore, the Board of Trustees reserves the right, in its sole discretion at any time and from time to time:
- To terminate or amend the amount or condition of any benefits, in whole or in part, even though such termination or amendment affects Claims which have already been incurred, at any time and for any reason with respect to active or retired Participants and their Dependents who are or who may become covered by the Plan.
- To alter or postpone the method of payment of any benefit.
- To change or discontinue the types and amounts of benefits under the Plan and the qualification rules, including but not limited to the rules for extended eligibility.
- To amend or rescind any other provisions of the Plan.
The Trustees do not promise to continue the benefits and coverage in full or in part in the future, and rights to benefits and coverages are not and under no circumstances will be vested or non-forfeitable. In particular, retirement or the completion of the requirements to receive a pension benefit under the SAG–Producers Pension Plan or under the AFTRA Retirement Plan does not give any Participant or former Participant any vested right to continued benefits or coverages under the Health Plan. If the Plan is amended or terminated, the ability of Participants, retirees or their family members to participate in and receive benefits from the Plan may be modified or terminated. The types and amounts of benefits are always subject to the actual terms of the Plan (and the provisions of any group insurance policies purchased by the Trustees) and to the Trust Agreement that establishes and governs the Plan’s operations.
Type of Benefits Provided by the Plan
The Plan provides Hospital, medical, prescription drug, mental health and substance abuse, dental, vision, life insurance and accidental death and dismemberment benefits. It also provides access to discounted eyewear.
Organizations Through Which Benefits Are Provided
The carrier listed below provides fully insured benefits under the Plan.
|MetLife Group Life Claims
(EDM America Building)
10 E.D. Preate Drive
Moosic, PA 18507
|Life insurance and AD&D benefits|
Metropolitan Life Insurance Company (MetLife) provides life insurance conversion policies.
The Plan is fully self-insured for the benefits obtained through the carriers listed below. These carriers administer at least a portion of the benefits for the Plan, but do not insure or otherwise guarantee any of the benefits of the Plan.
|Anthem Blue Cross
21555 Oxnard Street
Woodland Hills, CA 91367
|Administers the Hospital and medical benefits and provides access to its network of Hospital and medical care Providers|
|The Industry Health Network
23388 Mulholland Drive
Woodland Hills, CA 91364-2792
|Provides access to its network of medical Providers located in California|
|Express Scripts, Inc.
One Express Way
St. Louis, MO 63121
|Administers the prescription drug benefit and
provides access to its network of retail pharmacies
and its home delivery pharmacies (Express Scripts
Pharmacy and Accredo Specialty Pharmacy)
|Beacon Health Options
10805 Holder Street
Cypress, CA 90630
|Administers the mental health and substance
abuse benefit and provides access to its network of
behavioral health care Providers
999 3rd Avenue, Suite 1800
Seattle, WA 98104
|Administers the Quit for Life® smoking cessation
program and provides access to Quit Coach® staff
|Delta Dental of California
100 First Street
San Francisco, CA 94105
|Administers the dental benefit and provides access
to its network of dental Providers
3333 Quality Drive
Rancho Cordova, CA 95670
|Administers the vision benefit and provides
access to its network of vision care Providers
Requirements With Respect to Eligibility for Participation and Benefits
The eligibility requirements are outlined on pages 8-29 of this SPD. Eligibility rules for staff of SAG-AFTRA (the union), the SAG-AFTRA Foundation, the SAG-Producers Pension Plan, the AFTRA Retirement Fund and the Industry Advancement and Cooperative Fund are outlined in a supplement to the SPD.
Circumstances Resulting in Disqualification, Ineligibility or Denial or Loss of Benefits
Loss of Earned Eligibility is described on pages 35-36 of this SPD. Loss of Earned Eligibility for staff of SAGAFTRA (the union), the SAG-AFTRA Foundation, the SAG-Producers Pension Plan, the AFTRA Retirement Fund and the Industry Advancement and Cooperative Fund are outlined in a supplement to the SPD.
Loss of COBRA Continuation Coverage is described on pages 42-43 of this SPD.
Audit verification procedures and the recovery and offset of future benefit payments are described on pages 121-123 of this SPD.
Expired Check Limit
Replacement checks will not be issued for any lost or expired checks if more than four years have elapsed from the date of issue.
Procedures to Follow for Filing a Claim
The procedure to be followed in filing a Claim for benefits is described on pages 102-105 of this SPD.
No Liability for the Practice of Medicine
While the Plan provides covered Participants and covered Dependents with health benefits, neither the Plan, the Plan administrator, nor any of their designees are engaged in the practice of medicine. None of them has any control over any diagnosis, treatment, care or lack thereof, or any health care services provided or delivered to you by any health care Provider. Neither the Plan, the Plan administrator, nor any of their designees, will have any liability whatsoever for any loss or injury caused to you by any health care Provider by reason of negligence, failure to provide care or treatment, or otherwise.
Facility of Payment
Every person receiving or claiming benefits through the Plan will generally be presumed to be mentally and physically competent and of age. However, if the Plan administrator (or its designee) determines that a person entitled to receive benefits here under is a minor or is physically or mentally incompetent to receive the payment or to give a valid release for benefits, the Plan may issue payments to the person’s legally appointed guardian, committee or representative (upon proof of the appointment) or, if none, to another person or entity that the Trustees determine appropriate in their sole and absolute discretion. Any payment made in accordance with this provision will discharge entirely the obligation of the Plan.