USING THE PLAN’S MANAGED CARE NETWORKS

The Health Plan uses managed care networks for many benefits, including hospital, major medical, dental, mental health, chemical dependency, prescription drug and vision care benefits. All of the providers in these networks are carefully monitored to ensure that they continue to meet high professional standards and deliver services in the most effective way. However, just because you obtain care from a network provider, it does not mean that all services and supplies are automatically covered. If you have questions regarding coverage of a particular treatment, diagnostic test or supply, it is strongly recommended that you contact the Plan Office for coverage information rather than rely on a physician or his or her staff who deal with many different plans on a daily basis.

Savings
When you use the managed care networks, both you and the Plan save money because the network providers have agreed to accept a designated fee schedule, called the contract allowance, for their services. In some cases, you are required to use the network in order to receive any benefits. In other cases, you may choose whether or not to use the network.

Convenience
Using the managed care networks is convenient. The provider will complete and submit the claim forms for you. You must verify that the provider is in the network prior to each visit and then simply show your Screen Actors Guild-Producers Health Plan identification card when you arrive for your appointment. The provider will usually collect your co-payment at that time. After the claim is processed, the Plan’s payment will be made directly to the provider. You will receive notification from the Plan Office that the payment has been made. This notification is called an Explanation of Benefits
(EOB).

Determining Your Network
Most Health Plan participants, have access to the Plan’s managed care networks. For hospital and medical services, there is one network in California and another outside of California. You must use the network for the state where services are performed.

For example, if your primary residence is New York, you normally utilize the PHCS network for hospital and major medical services. However, if you need to see a doctor while visiting in California, and want the network level of benefits, you must call the Blue Cross network phone number listed on the back of your I.D. card and locate a Blue Cross Prudent Buyer provider. Present your I.D. card at the time of service. Conversely, if your primary residence is California, you normally use BlueCross for hospital and major medical services. When you travel out of California you must use PHCS providers in order to receive the network level of benefits.

Locating a Network Provider
Provider directories are not printed for distribution because new providers are continually being added to the networks, which means the directories become outdated very quickly. You can always find out if a particular provider is in the network or obtain a list of providers in your area at no charge by contacting the networks at the numbers or Web sites shown in the chart on the next page.

IMPORTANT: The providers in these networks change on an ongoing basis. New providers are added and old providers drop out. Some providers offer services at more than one location and not all locations may be in the network. It is your responsibility to make sure that the provider is in the network at the location where you receive services at the time you receive care.

The Industry Health Network of the Motion Picture and Television Fund
The Health Plan has also made arrangements with The Industry Health Network (TIHN), a wholly owned subsidiary of the Motion Picture and Television Fund. Although located only in California, it is available to all SAG Producers Health Plan participants. Its network of physicians and outpatient health centers offers the least expensive option for quality care because when you use an Industry Health Network facility and an Industry Health Network primary care physician (PCP), you have lower annual deductibles and only minor co-payments.

To take advantage of this program, visit a PCP at one of the health centers. The PCP will coordinate your care and, if necessary, will refer you to a specialist in The Industry Health Network. Without the PCP’s referral, the Industry Health Network level of benefits will not apply. This means you will have higher deductibles and/or co-insurance. To establish a relationship with a PCP, please contact one of the conveniently located health centers and make an appointment.

Click here for new Health Care Center

Bob Hope Health Center
335 North La Brea Avenue
Los Angeles, CA 90036-2584
(323) 634-3850

Santa Clarita Health Center
25751 McBean Parkway, Suite 210
Valencia, CA 91355-3702
(661) 284-3100

Toluca Lake Health Center
4323 Riverside Drive
Burbank, CA 91505-4044
(818) 556-2700

Westside Health Center
1950 Sawtelle Boulevard, Suite 130
Los Angeles, CA 90025-7014
(310) 996-9355

Jack H. Skirball Health Center
23388 Mulholland Drive
Woodland Hills, CA 91364-2792
(818) 876-1050

* Participants who live more than 25 miles from two providers of any type who participate in the hospital/major medical network available to them (Blue Cross in California and PHCS outside of California) are considered to be outside a network area but will receive the network level of reimbursement for hospital and medical services. However, if they travel to a network area, they must use network providers to obtain the higher level of benefits.

If a participant who lives in a network area is being treated for a serious condition that requires a specialist’s care, and there are no network specialists in his or her area, the participant will receive the network level of benefits for services rendered by that specialist. A serious condition includes conditions such as cancer and cardiac surgery. It does not include situations of a non-serious nature, such as claims for chiropractic or acupuncture.

You are responsible for the lower network deductibles and co-payments and the difference between the Plan’s Allowance and the billed amount. The Plan’s Allowance will be used to determine the amount the Plan will consider instead of the lower network contracted amount.