SAG-AFTRA Stand Alone Dental & Vision Plan

SAG-AFTRA has brought you Dental and Vision coverage regardless of earnings requirements

SAG-AFTRA has arranged for a Stand Alone Dental and Vision insurance plan for Union members who are NOT enrolled in the SAG-AFTRA Health Plan I / II.

This benefit provides coverage for you and your eligible dependents for Preventive, Basic and Major dental services, such as exams, cleanings, x-rays, fillings, crowns, root canals, and Implants. In addition, this plan includes a vision benefit program.

These programs are only available to SAG-AFTRA Union members in good standing or on honorable withdrawal.

These programs have been arranged through your Union as part of its continuing efforts to provide members access to additional benefits. They will be administered by Group Benefit Associates and Cigna, not SAG-AFTRA or the SAG-AFTRA Health Plans.

Eligibility

  • SAG-AFTRA Union members in good standing or on honorable withdrawal
  • SAG-AFTRA members that are NOT covered under the SAG-AFTRA Health Plan I or Plan II
  • Surviving dependents of SAG-AFTRA members

In order to participate, the individual must be and remain current with any union dues that are required under SAG-AFTRA rules.

Eligible Dependents include:

  • Your legal spouse
  • Qualified Domestic Partners
  • Your dependent children (dependent children are eligible until age 26)
  • Legally adopted children
  • Step-children who depend on you for most of their support and maintenance

 

The Dental Benefit

This plan offered by Group Benefit Associates and insured by Cigna, gives members the opportunity to choose either a Dental PPO Plan or a Dental DHMO Plan. This flexibility allows you to select the plan that best fits your specific needs and budget. The Dental DHMO Plan is offered in California, New York, New Jersey, Illinois, Florida and Texas. The Dental PPO Plan is offered in all 50 states. Both the Dental PPO and the Dental DHMO Plan include a Vision benefit. See this DHMO FLYER for more information on the Cigna DHMO Plan.

The Dental PPO Plan option:

The Dental PPO plan allows you to visit any dentist or specialist you choose any time care is needed. If you elect to visit a Cigna network provider, you will receive the highest level of benefits and save on out-of-pocket costs. Best of all, the Cigna Dental PPO Plan features one of the industry’s most extensive nationwide dental networks.

The plan pays a specific amount for each dental service based upon an established fee schedule. If you go to a Cigna Dental PPO provider, the benefits described below apply. If you go to a non-Cigna provider, the amounts charged over the scheduled fees are the patient’s responsibility.

Cigna PPO Advantage
Cigna PPO
Out-Of-Network Providers
Calendar Year Deductible
(waived for Preventive services)
$50 Individual
$150 Family
$75 Individual
$225 Family
$75 Individual
$225 Family
Preventive Services
Exams, Cleanings, X-Rays, Fluoride, Sealants, Space Maintainers
100% of fee schedule, no deductible
75% of fee schedule, no deductible
75% of fee schedule, no deductible
Basic Services
Fillings, Oral Surgery, Anesthetics, Periodontics, Root Canal / Endodontics
Repair Bridge / Crown / Inlays / Dentures
80% of fee schedule, after deductible
80% of fee schedule, after deductible
50% of fee schedule, after deductible
Major Services
Crowns / Inlays / Onlays, Dentures, Bridges
50% of fee schedule, after deductible
50% of fee schedule, after deductible
50% of fee schedule, after deductible
Orthodontia
not an insured benefit
not an insured benefit
not an insured benefit
Implants
50% of fee schedule, after deductible, $1000 yearly
50% of fee schedule, after deductible, $1000 yearly
50% of fee schedule, after deductible, $1000 yearly
Calendar Year Maximum Benefit
$1000, $1200, $1400, $1600
Years 1,2,3,4
$1000, $1200, $1400, $1600
Years 1,2,3,4
$1000, $1200, $1400, $1600
Years 1,2,3,4
PRE-DETERMINATION: When a course of treatment is expected to cost $200 or more and is of a non-emergency nature, it is recommended to have your dentist submit a treatment plan before he/she begins.

This is intended only as a brief summary of benefits. It is not an official statement of those benefits. Please see additional docs under the “Plan Details” Tab above.

The Dental DHMO Plan option (only available in CA, NY, NJ, IL, FL and TX):

The Dental DHMO Plan is designed to provide quality dental care while controlling the cost of such care. To do this, this plan requires participants to seek dental care from dentists that belong to the Cigna Dental DHMO network. All covered services must be provided by the participant’s Primary Care Dentist selected at the time of enrollment.

You are only covered if you go to your assigned Primary Care Dentist
Specialty Referrals
Must be coordinated by your Primary Care Dentist
Calendar Year Deductible
None
Office Visit Co-pay
$5
Preventive Services
Oral Exams, Cleaning, X-Rays, Sealants, Space Maintainers
May be an additional fee. Refer to the DHMO Copayment Schedule for your state. See “Plan Details” tab.
Basic Services
Fillings, General Anesthesia, Scaling & Root Planing, Simple Extractions, Endodontics, Periodontics
Available for a Copayment. Refer to the DHMO Copayment Schedule for your state. See “Plan Details” tab.
Major Services
Dentures, Single Crowns, Prosthodontics
Available for a Copayment. Refer to the DHMO Copayment Schedule for your state. See “Plan Details” tab.
Orthodontia
Available for a Copayment. Refer to the DHMO Copayment Schedule for your state. See “Plan Details” tab.
Calendar Year Maximum Benefit
Unlimited

DHMO Copayment Schedules are available on the “Plan Details” tab above.

 

The Vision Benefit

Vision benefits are provided through Cigna Vision and include an annual eye exam for a $10 co-pay, in addition to discounted rates on frames, lenses, and other professional services. This benefit also includes discounts on all covered services such as LASIK.

Our vision plan allows you to visit any eye doctor you wish. However, you save significantly on out-of-pocket costs when network providers are used. You will receive substantial coverage for annual eye exams and discounts on eyewear and contact lens professional services every 12 months.

 

You can find a provider near you by:
  1. Clicking Find an Eye Doctor to search the online directory.
  2. Requesting a provider directory by calling (877) 478-7557.

 

Covered Services & Value Added Discounts

Eye Exams:
  • $10.00 copay, covered in full thereafter
Glasses:
  • 20% off lenses, frames and the industry’s most extensive list of “cosmetic extras”, including tints, special lenses (e.g. progressives) and scratch resistant coatings.
  • 20% off the retail price of additional glasses after initial pair is purchased.*
Contact Lenses and Professional Services
  • 15% off of the network doctor’s evaluation and fitting services.
  • 20-25% off laser vision correction, or 5% off the laser surgery center’s best promotional price, whichever is a better deal!**

You should call the provider to schedule an appointment. When calling to schedule the appointment, identify yourself as a Cigna member and give the insured’s social security number.

*The claimant must go within 12 months to the same doctor who provided the exam.
**Laser surgery is not an insured benefit. The surgery is available at a discounted fee. The covered person must pay the entire discounted fee. In addition, the laser surgery discount may not be available in all states. participant’s out-of-pocket costs won’t exceed $1,800 per eye for LASIK and $1,500 per eye for PRK.

The Stand Alone Dental and Vision Plan is offered as a combined package. All monthly premiums are collected on the 15th of the month prior to the month in which the premium is due.

2021 Monthly Premium for Dental and Vision

The PPO Plan

Participant
Participant + 1
Participant +2+
All 50 States
$53.45
$96.32
$116.44

The DHMO Plan

Participant
Participant + 1
Participant +2+
California
$28.73
$43.27
$63.98
NY, NJ, TX
$27.11
$38.19
$50.07
Florida, Illinois
$30.31
$47.68
$72.38

 

The Dental DHMO Plan is only available in California, Florida, Illinois, New Jersey, New York, and Texas. Purchase coverage in the state where you receive your dental care.

Cancellation Requests: Cancellation requests must be received in writing by mail, fax, or e-mail. Cancellations will become effective on the last day of the month in which they are received.

Premium Payments: Your initial premium due will be collected within 5 business days of your enrollment. Subsequent premiums will be collected automatically from a Visa, MasterCard or direct debit from a checking account on the 15th of each month. If the 15th falls on a weekend or holiday, the charge will occur on the next business day.

Forms & Documents

The following documents below are provided for your reference:

Enrollment Form

PPO Dental Summary

DHMO FAQ Flyer

Vision Summary

DHMO Copayment Schedule California

DHMO Copayment Schedule Florida

DHMO Copayment Schedule Illinois

DHMO Copayment Schedule New York, New Jersey, Texas

Dental Claim Form

Vision Claim Form

Parental Consent Form for Children under age 13

Prescription Discount Card

 

Frequently asked questions:

Q: How can I cancel my policy?

A: Please send your cancellation request by email, fax or mail.

 

Q: How can I get an ID card?

A: Please call Cigna at 800-244-6224 to request an id card.

 

Q: I have the DHMO Plan and I would like to change my provider?

A: Please call Cigna at 800-244-6224 to change your DHMO provider.

 

Click below to enroll online

OR

DOWNLOAD and print the enrollment form and fax or mail it to us.

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