Health Plan Information
For purposes of clarity, the Plan's provisions have been summarized. We emphasize that nothing in this explanation is intended to change the provisions of the Plan and that only the Board of Trustees is authorized to interpret the Plan. In the event any question is raised, the rights of Plan participants will be determined in accordance with applicable Plan language and by the rules and regulations adopted by the Board of Trustees in the course of the administration of the Plan. The Board of Trustees reserves the right to interpret, alter or amend the Plan. Updated copies of the full Plan documents are available to Plan participants and beneficiaries from the Plan Office.
For more information, please refer to the January 2010 Health Plan Booklet and updates.
The DGA-Producer Health Plan
One of the important benefits of working for DGA signatory employers is the Directors Guild of America - Producer Health Plan. The Health Plan began in 1969, and since then has paid health benefits for tens of thousands of participants and their eligible dependents. The Board of Trustees is pleased to provide one of the finest benefit packages in the industry.
This site provides only a brief description of the eligibility requirements and the benefits. Detailed information regarding the Health Plan can be found in the January 2010 Health Plan Booklet and updates. All Plan participants should have received a copy of the booklet. Participants who do not have a booklet should call the Health Plan office.
Two Kinds of Health Plans
Participants eligible for health coverage are covered under the self-insured DGA-Producer Health Plan. In addition to the DGA-Producer Health Plan, an HMO option is available to California residents under age 65 through HealthNet.
Under the DGA-Producer Health Plan, participants can choose any doctor. However, both the participant and the Health Plan save money when the participant chooses network providers.
There are separate out-of-pocket maximums and co-insurance for network and non-network doctors. Under the HMO option, participants must choose an HMO-affiliated doctor, but there is no deductible, a smaller co-pay and different benefits are covered.
Effective August 11, 2006, network providers must submit claims by the earlier of:
- the claims submission deadline provided in their provider policy or procedure, or;
- one year after the date of service.
This site summarizes benefits under the DGA-Producer Health Plan only, as the HMO has different benefit provisions. Participants who want information on the HMO in California should contact the Eligibility Department or HealthNet.
Health Benefits for Participants and Family Members
The Health Plan provides benefits for participants and their eligible dependents. After meeting the eligibility requirements, benefits may be payable for:
- Medical expenses;
- Hospital expenses;
- Prescription drugs;
- Vision care;
- Dental care;
- Psychiatric care;
- Chemical dependency treatment;
- Wellness benefits; and
- Hospice care.
Two Plans: DGA Choice and DGA Premier Choice
There are two levels of benefits within the DGA Health Plan: the DGA Choice Plan and the DGA Premier Choice Plan. The services covered under each of these plans are the same, the only difference is the applicable non-network out-of-pocket limit and co-insurance for each plan. When network providers are utilized, there is no difference between the DGA Choice and DGA Premier Choice Plans. For more information on the DGA Choice Plan and the DGA Premier Choice Plan, please refer to the DGA Choice and Premier Choice Plans section of the January 2010 Health Plan Booklet.
How and When am I Eligible for Benefits?
Guild membership does not ensure Health Plan participation. In order to participate or become eligible you must work in DGA Covered Employment and meet the minimum earnings requirement for Earned Coverage.
For earnings periods beginning in 2010, $33,400-$100,999 in earnings for DGA covered employment qualifies you for one year of DGA Choice Plan coverage, and $101,000 or more in earnings for DGA covered employment qualifies you for one year of DGA Premier Choice Plan coverage. The Trustees generally increase the minimum earnings threshold annually based on increases in the Collective Bargaining Agreements between the Guild and Producer employers. To be sure of the current minimum earnings threshold, please contact the Health Plan office.
Benefit periods last for 12 months and begin only on calendar quarter dates (January 1, April 1, July 1 or October 1). Because of the time needed to receive and process contributions on your behalf, there is a mandatory three-month waiting period between the time you generate minimum earnings (earnings period) and the time your coverage begins (benefit period).
For detailed information about earning and benefit periods, including an illustrative chart, please refer to Qualifying for Coverage.
Under certain circumstances your coverage or right to self-pay continues even when you do not generate enough earnings to qualify for Earned Coverage. This may occur through:
- Self-Pay/COBRA coverage;
- Certified Retiree Coverage; or
- Carry-over Credits.
How Much Do These Benefits Cost Me?
There is no charge for participant-only coverage. However, there is an annual premium charged for dependent coverage. In order for a participant's eligible dependents to be covered under his or her health coverage, the dependent premium must be paid. Please note that one dependent premium covers all of a participant's eligible dependents.
Also, the Health Plan does not cover 100% of your medical expenses. Some expenses are not covered by the Plan at all; cosmetic surgery, for example. Some expenses have a dollar limitation; for example, substance abuse expenses have a lifetime maximum of $30,000 (substance abuse treatment must be authorized by OptumHealth, the Health Plan's mental health and chemical dependency benefit manager). Other forms of treatment have an annual maximum, such as the 20-visit maximum for chiropractic services.
For The Medical Plan you share expenses through annual deductibles and co-payments. There is a $325 ($975 for a family) deductible amount you pay before the Plan pays for covered expenses. Once you satisfy the annual deductible, the Plan pays 90% of the Reasonable and Customary charges if services are provided through a network provider. If you do not use a network provider, the Plan pays 70% for DGA Premier Choice Plan participants and 60% for DGA Choice Plan participants. Some treatments pay at a lesser rate, however. For instance, outpatient psychiatric pays at 50%.
Network doctors and hospitals are contracted with Anthem Blue Cross' BlueCard® network. To find a PPO doctor or hospital, check Anthem Blue Cross' online Provider Finder or call the Plan office at (323) 866-2200 or (877) 866-2200.
The Prescription Drug Plan
The Prescription Drug Plan is provided through Medco. When you have your covered prescription filled, simply present your card at a Medco- participating pharmacy. The pharmacy will charge you $10 for generic drugs and $24 for brand name drugs at that time, excluding certain lifestyle drugs. There are no forms to fill out and no claims to send in. Mail order prescriptions for 90-day supplies have a $25 co-payment for generic prescriptions and a $60 co-payment for brand name drugs. There is no deductible associated with the prescription drug program, and your prescription drugs do not count towards your annual out-of-pocket or stop-loss amounts.
Erectile dysfunction medication, proton pump inhibitors, non-sedating antihistamines and sleep aides are included in the lifestyle drugs tier. These drugs are covered at 50% co-insurance with a minimum $40 co-payment when obtained at a pharmacy and a minimum $60 co-payment when obtained through the mail order program.
Only those participants for whom the DGA Plan is primary should use the DGA Plan's Medco drug card. If the DGA Plan is secondary, prescription drugs should be purchased through your primary plan. For example, your spouse or dependent child may be primary under a health plan sponsored by your spouse's employer, and the DGA Plan would be secondary. Or you may have coverage with us, but your primary plan is the Screen Actors Guild Plan. In those cases, do not use your drug card when purchasing your prescriptions. However, you may be entitled to partial reimbursement from us under coordination of benefits. To file a claim in cases where we are your secondary plan, you may request a Medco Claim Form from the Plan Office and submit this form to Medco. In cases where Medicare is primary and we are secondary, the Plan's prescription drug plan is primary for your drug purchases.
You may purchase your prescription drugs at any pharmacy and still be reimbursed; it does not have to be a Medco-participating pharmacy. Be aware, however, that you cannot use the card program at a non-participating pharmacy, you will not receive the discount on the cost of your prescription, and you will have to pay in full at the time of purchase. To file a claim for prescriptions purchased at a non-network pharmacy, you must submit your receipts and a Medco Claim Form to Medco and they will reimburse you for the amount that they would have covered (the discounted price less the co-payment amount).
The Health Plan features a mandatory mail order policy for most long-term prescriptions. Under this policy, Plan participants will pay significantly less for their long-term prescriptions by filling them through Medco by Mail, Medco's mail-order prescription service. Convenient and easy-to-use, Medco by Mail allows Health Plan participants to obtain the same long-term prescriptions that they would get at a retail pharmacy at a lower co-payment. Currently, mail order co-payments are nearly 17% lower than the retail co-payment for the same amount of a prescription. Plan participants pay the entire cost of covered medications that are taken on a long-term basis (3 months or more) if the medications are purchased at a retail pharmacy.
In cases where a drug is not available through Medco by Mail, Health Plan participants will only pay the applicable retail co-payment when the medication is purchased through a Medco-participating retail pharmacy. In addition, Medco by Mail does not deliver outside the United States. Plan participants who are leaving the country for extended periods of time may contact the Health Plan office to make arrangements to obtain a vacation override on their prescriptions. Participants may also submit claims for covered medications that are obtained at foreign pharmacies.
For more information about Medco, you can contact them at (800) 987-7828 or go to their website.
The Dental Plan
The Dental Plan is administered by Delta Dental of California. Network dentists are contracted with Delta Dental as part of the DeltaPreferred Option. When you use a network dentist, there is no deductible and benefits are paid at a higher percentage for most procedures.
When using a network dentist, there is no deductible. Dental expenses are covered at either 100%, 80% or 70%, depending on the type of treatment. Oral exams and cleaning are paid at 100%, fillings and crowns at 80%, endodontics and implants at 70%, for example.
When using a non-network dentist, there is a $50 ($100 for a family) annual deductible that is separate from the medical plan. Dental expenses are covered at either 85%, 60% or 50%, depending on the type of treatment. Once the deductible is met, the Plan pays at varying rates for different categorized procedures. Oral exams and cleaning are paid at 85%, fillings and crowns at 60% and endodontics and implants at 50%, for example.
The maximum amount payable for covered dental expenses during a calendar year is $2,500 per individual.
Orthodontia for dependent children under age 19 is also covered at 50%. There is a $1,500 lifetime maximum for orthodontia treatment.
For more information about Delta Dental, you can contact them at (800) 846-7418 (for benefits, claims and eligibility information) or (800) 427-3237 (to find a network dentist) or go to their website.
The Vision Plan
The Vision Plan has separate $30 co-payments for examinations and lenses/frames. There are also covered expense limitations as scheduled by Vision Service Plan (VSP), our provider. In general, the vision plan covers eye exams, lenses, frames and contact lenses. The amount covered can be found in the January 2010 Health Plan Booklet or through the VSP website. You can also find a VSP participating doctor through their website.
For more information about VSP, you can contact them at (800) 877-7195 or go to their website.
This Sounds Great, but Who Pays for All This?
When you work in DGA-covered employment, your employer makes a contribution to the Health Plan based on your covered salary. The percentage that is contributed is determined by which collective bargaining agreement you are working under at the time of your earnings. You share in health care costs through the dependent premium, deductibles, co-insurance and co-payments.
It is very important that you check that contributions are being paid to the Plan on your behalf when you work in DGA-covered employment. The Plan sends quarterly statements to each participant who had earnings during the quarter. Look over your quarterly statements! The statement shows the contributions made on your behalf by each of your employers.
If your records differ from ours, contact the Contributions Department in the Plan Office immediately. Non-receipt of contributions can jeopardize your Health Plan eligibility.