• How will Retiree Health Credits be earned under the SAG-AFTRA Health Plan?

    Effective January 1, 2023, a participant who has covered sessional earnings of at least $27,000 in a calendar year will earn a Retiree Health Credit for that year. 

  • What are premium rates for senior performers?

    Please see Premiums for current rates.

  • Why is the premium higher for participants with a spouse under the age of 65?

    Currently the Plan is paying as the primary plan for spouses under the age of 65 because they are not yet eligible for Medicare. Costs are much higher for these spouses than for Medicare-eligible spouses.

  • I would like to cancel pension deduction and change my payment method. Can I cancel pension deduction online?

    No. A completed Payment Election Change Request form or written request must be received and processed by the Plan before you can use a different payment option.

  • When my spouse turns age 65, do I need to submit anything to change my rate?

    No, there is no paperwork to submit. Your premium will automatically be adjusted to the lower premium rate effective the first of the month in which your spouse turns age 65. For example, if you are paying $120 per month and your spouse turns age 65 on May 15th, your premium will be $60 per month effective May 1st.

    If you are on pension deduction or automatic payment, the rate will automatically adjust effective the first of the month in which your spouse turns age 65.

  • Will I receive Retiree Health Credits under the SAG-AFTRA Health Plan for years of service I earned toward retiree health eligibility under SAG Plan and/or AFTRA Plan?

    Yes.  You will receive credit for the greater number of retiree health years of service (i.e., SAG Pension Credits or AFTRA Qualifying Health Years) that you already earned towards retiree health coverage under either the SAG Health Plan prior to January 1, 2017 or the AFTRA Health Plan prior to December 1, 2016.

    If you have credits/years in both Plans, the higher number transfers to the SAG-AFTRA Health Plan.

    However, you will receive additional credits for any retiree health years of service earned under the Plan with the lower number of credits/years if:

    They are SAG Pension Credits earned from January 1, 2009 through December 31, 2016

    or

    They are AFTRA Qualifying Health Years earned from December 1, 2008 through November 30, 2016.

    The 12-month period in which you earned the retiree health year of service does not overlap by more than one month with any 12-month period for which you received a year of retiree health eligibility under the Plan in which you have the higher number of credits/years.

    EXAMPLE: If you have 13 AFTRA Qualifying Health Years and 10 SAG Pension Credits, you would receive 13 Retiree Health Credits in the SAG-AFTRA Health Plan.

    But if 3 of your 10 SAG Pension Credits were earned between January 1, 2009 and December 31, 2016 and you have no overlapping AFTRA Qualifying Health Years earned during the same period, you would receive 3 additional Retiree Health Credits in the SAG-AFTRA Plan.

    So in this example, you would begin 2017 with 16 Retiree Health Credits.

Eligibility

Premiums

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

    If your payment is not received by the due date, including the grace period, you may reinstate your coverage by using a late payment waiver. For Earned Eligibility, the Plan allows one late payment waiver per three-year waiver period. The first three-year waiver period begins on January 1, 2023 and is reset every three years thereafter.

    The three-year reset period applies to all Participants and is not dependent on when you use a waiver. For example, if you use your one waiver in March 2024, you will again have a waiver available as of January 1, 2026. Senior Performer Dependents and Senior Performer Surviving Dependents 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 the payment is due.

  • 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 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.

  • What are the premium rates?

    Please see Premiums section for current premium rates. 

  • 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.

  • 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.

  • 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.

  • 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 30-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.

Benefits

  • 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.

  • 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.

  • 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. 

  • 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).

  • 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.

  • 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.

  • 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.

  • When is a pre-authorization required for Plan benefits?

    Pre-authorizations are required for eyelid, nasal and certain breast surgeries because these procedures often fall under the cosmetic exclusion.

    Pre-authorizations are also required for back surgery, bariatric surgery, gender reassignment surgery, neuro-psychological testing, organ transplants, outpatient private duty nursing and sleep studies.

    Please have your Physician submit a request of the proposed procedure, including the procedure codes, along with a copy of the history and physical report, clinical notes and test results. For eyelid, nasal and breast surgeries your Physician must also include diagnostic quality preoperative photographs.  Physicians may fax their request to the Pre-Authorization department at (818) 973-4473.

  • 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.

  • 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 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.

  • 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.

  • 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. 

Prescriptions

  • Do I have to use CVS Caremark Mail Service Pharmacy?

    The Plan allows two 30-day fills at any pharmacy in our network. After that, the Plan will cover long-term medications only if 90-day supplies are filled through CVS Caremark Mail Service Pharmacy or at a CVS Pharmacy location. Whether your dependent(s) choose delivery or pickup, the copayment will remain the same. This choice is being offered by the SAG-AFTRA Health Plan as a way to help save on prescription costs. If your dependent(s) continue to fill their long-term prescriptions in 30-day supplies at a retail pharmacy after two times, the Plan will not cover the medications and they will have to pay the entire cost. For help in managing 90-day supplies, we encourage online registration for access to the maintenance tools.  

  • How do I use CVS Caremark Mail Service Pharmacy

    • CVS Caremark make the transition easier by transferring any prescription you’re currently filling by mail to CVS mailboxCaremark Mail Service Pharmacy as long as you have refills left. If you’re not sure about your refills, check your current prescription bottle. The only prescriptions we can’t transfer are compound medications and controlled substances – you will need to get a new prescription for these medications. If you are unsure if your medications are compounds or controlled substances, ask your doctor. 

      Don’t have any refills left? No worries –  Simply visit Caremark.com/MailService and request a new prescription. CVS Caremark will contact your doctor and handle all the details for you. Or, you can ask your doctor to send a new prescription to CVS Caremark. 

       Download the mail service order form. This order form will be included in the Welcome Kit that you will receive from CVS Caremark.

      Please note: Your preferences for automatic refills will not be transferred to CVS Caremark. You’ll need to sign in to Caremark.com  to start automatic refills with CVS Caremark Mail Service Pharmacy. 

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.

COBRA

Medicare