SAG-AFTRA Health Benefits

For 2022, the minimum earnings requirement for Plan I eligibility is $25,950 during your 12-month Base Earnings Period. 

2022 Benefits Summary

- Hospital

Calendar Year Deductible

BlueCard PPO/Beacon Health Options -

$500 / person; $1,000 / family
(combined w/ Medical)

Not covered

Inpatient (Room and Board and Ancillary Services)

90% of contract rate after $100 copay

Not covered*

Outpatient Surgery

90% of contract rate after $100 copay

Not covered

Emergency Room

90% of contract rate after $100 copay; emergency room copay is waived if immediately confined

Not covered*

Coinsurance Out‐of‐Pocket Limit

$2,750/person; $5,500/family Combined hospital and medical (including MHSA)

Not covered

- Medical***

Calendar Year Deductible

BlueCard PPO/Beacon Health Options ‐ $500 / person; $1,000 / family (combined w/Hospital)

$500/person; $1,000/family

Office Visit

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

Medical: 60% of Plan's allowance
MHSA: 70% of Plan's allowance

Surgeon

90% of contract rate

60% of Plan's allowance

X‐ray and Lab

90% of contract rate

60% of Plan's allowance

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

90% of contract rate

60% of Plan's allowance

Maternity Care ‐ Prenatal Visits

No deductible; 100% of contract rate

60% of Plan's allowance

Maternity Care ‐ Delivery

90% of contract rate

60% of Plan's allowance

Routine Physical Exam

No deductible; 100% of contract rate

60% of Plan's allowance

Routine Child Exam

No deductible; 100% of contract rate

60% of Plan's allowance

Routine Mammogram/Pap

No deductible; 100% of contract rate

60% of Plan's allowance

Hearing Aids

90% of contract rate up to a maximum payment of $1,500 per device; one device per ear per
three-year period

60% of Plan's allowance up to a maximum payment of $1,500 per device; one device per ear per
three-year period

Coinsurance Out‐of‐Pocket Limit

$2,750 / person; $5,500 / family
Combined Hospital and Medical (including MHSA)

None

- Overall Out‐of‐Pocket Maximum

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

$8,700/person; $17,400/family

None

- Mental Health and Substance Abuse

Beacon Health Options In‐Network Provider

Out‐of‐Network Provider

Hospital and Alternative Levels of Care**

Covered under Hospital Benefit

Not covered*

Medical

Covered under Medical Benefit

Covered under Medical Benefit

- Dental

Delta Dental PPO In‐Network Provider

Delta Premier and Out-of‐ Network Provider

Deductible

$75/person; $200/family

$75/person; $200/family

Diagnostic and Preventive Benefits

No deductible; 100%

75%

Basic Benefits

75%

75%

Major Benefits

50%

50%

Calendar Year Maximum^

$2,500

$2,500

- Vision - Exam Plus Plan

Vision Service Plan (VSP) In‐Network Provider

Out‐of‐Network Provider^^^

Eye Exams

100% after $10 copay;

One Exam Per Calendar Year

80% up to a maximum

Payment of $50; One Exam Per Calendar Year

Glasses

20% discount

No benefit

Professional Services for Contact Lenses

15% discount

No benefit

- Prescription Drugs (CVS Caremark)

CVS Caremark Participating Retail Pharmacy

CVS Caremark Home Delivery

Calendar Year Deductible

$75/person; $150/family

$75/person; $150/family

Supply

Up to 30 day supply prescription or refill

Up to 90 day supply prescription or refill

Copay for Generic

(Tier 1)- $10 or 10%

(Tier 1) - $20 or 10% ; max copay is $50/ prescription

Copay for Preferred Brand

(Tier 2) - $25 or 25%

(Tier 2) - $50 or 25% ; max copay is $125/ prescription

Copay for Non‐Preferred Brand

(Tier 3) - $40 or 40%

(Tier 3) - $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 preventive services medications, including contraceptives, are covered at 100% with no deductible or copay.

* The Affordable Care Act (ACA) defines certain care as essential benefits that must fall under health insurance covered. All other benefits and certain specialty medications are defined as non-essential. 

 **Alternative levels of care include Residential Treatment Center, Partial Hospital Program and Intensive Outpatient Program.          

***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.

****RX Savings Solutions is an online service through which you and your enrolled dependents can find prescription medications at a lower cost. Register at myrxss.com.       

^There is no dental maximum for individuals under age 19.   

^^^Contact VSP at 800-877-7195 or www.vsp.com for Out-of-Network Provider allowances.