Health Summary Plan Description

Using The Plan's Network Providers

As of January 1, 2016, ValueOptions is now Beacon Health Options. For more information, please see the Winter 2015 Take 2.

The Health Plan uses networks of preferred providers for its hospital, medical, mental health, substance abuse, prescription drug, dental 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 network providers, both you and the Plan save money because the network providers have agreed to accept a designated fee schedule 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. If you choose to use a non-network provider you will receive a lower level of benefits.

Convenience

Using network providers is convenient. The provider will complete and submit the claim forms for you. You must verify that they are in the network prior to each visit and then simply show your Health Plan ID card when you arrive for your appointment. The provider will usually collect your copay 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).

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for distribution because new providers are continually being added to the networks which means the directories become outdated very quickly.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 visiting the Plan's website, www.sagph.org, or contacting the networks at the numbers or websites shown in the chart to the right.

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 MPTF (Motion Picture& Television Fund)

The Health Plan has also contracted with The Industry Health Network (TIHN), a wholly owned subsidiary of MPTF. It is available to all Health Plan participants although its health centers are located only in Southern California. Its network of physicians and outpatient health centers offers the least expensive option for quality care because when you use a TIHN primary care physician (PCP), the annual deductible does not apply. Also, if you use TIHN facilities for nonemergency care you will have a lower annual hospital deductible. Please note that the Motion Picture& Television Hospital does not provide emergency care.

To take advantage of this program, make an appointment with a PCP at one of the MPTF Health Centers. The PCP will coordinate your care and, if necessary, will refer you to a specialist in TIHN. Without the PCP's referral, the Industry Health Network level of benefits will not apply. This means you will have higher deductibles. You must see the PCP in person to receive a referral to a specialist; you cannot just call the PCP.

In order to receive services through the MPTF you must be at least 13 years of age. A TIHN referral to a pediatrician for children under the age of 13 may be obtained over the phone by calling TIHN customer service at (800) 876-8320.

To establish a relationship with a PCP, please contact one of the conveniently located health centers and make an appointment.

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

Glendale Health Center
800 South Central Avenue, #305
Glendale, CA 91204
(818) 876-4790

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

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

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

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

Preferred Provider Networks
Hospital and Medical BlueCard PPO*

(800) 810-BLUE (2583)
www.sagph.org
link to "Find Network Providers" then link to "BlueCard PPO"

The Industry Health Network (TIHN) (800) 876-8320
www.mptf.com/sagph
Prescription Drug Express Scripts (800) 903-4728
www.express-scripts.com
Mental Health and Substance Abuse
ValueOptions* (866) 277-5383
www.valueoptions.com/sagph
Dental Delta Dental (800) 846-7418
www.deltadentalins.com/sagph
Vision Vision Service Plan (800) 877-7195
www.vsp.com
All Networks Plan Office (818) 954-9400
(800) 777-4013
www.sagph.org

* If you need hospital or medical services and you live more than 25 miles from two providers of any type who participate in the BlueCard PPO network you are considered to be outside a network area but will receive the Network Level of Benefits for these services. However, if you travel to a network area, you must use network providers to obtain the higher level of
benefits. These same rules apply to Plan I participants who need mental health or substance abuse treatment and live more than 25 miles from two facilities or providers of any type who participate in the ValueOptions network.

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, copays and coinsurance plus 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.