Fox Valley and Vicinity Construction Worker's Welfare Fund

Downloadable Forms
Disability Form - Page 1
Disability Form - Page 2

Accident Information Form

Subrogation Acknowledgement Form - Page 1
Subrogation Acknowledgement Form - Page 2

Appointment of a Personal Representative Form

Caremark Mail Service Order Form - Page 1
Caremark Mail Service Order Form - Page 2

These forms will display correctly using the Adobe Acrobat Reader. The latest version can be found here.

Related Sites
Caremark
EyeMed
Blue Cross/Blue Shield

Contact Information
Telephone: 630-232-7166 ext. 777

Basic Benefit Information for the Fox Valley and Vicinity Construction Worker's Welfare and Pension Fund Active Plan:

Eligibility:
A participant becomes eligible on the first day of the Benefit Quarter following the Contribution Quarter for which 300 hours of contributions are received. To maintain eligibility, the participant must have at least:
 -270 hours for the Contribution Quarter immediately preceding the Benefit Quarter;
 -or 800 hours for the four Contribution Quarters immediately preceding the Benefit Quarter.

Medical Care:
The Plan's PPO (preferred provider organization) is Blue Cross Blue Shield (BCBS). To locate a provider you can either contact BCBS at 800-571-1043 or via their website at www.bcbsil.com. Benefits are calculated as follows:
-90% for claims with in-network providers and an out of pocket of $7,500;
-Out of network claims are paid at 70% and an out of pocket of $15,000;

The Plan's calendar year deductible is $200.00 per person and $400.00 per family. When you schedule an office visit for an illness you will need to pay the physician a $5.00 office visit co-pay. The office will then be paid at the applicable percent, but your office visit is not subject to the calendar year deductible. The Plan's lifetime maximum is $1,000,000.

Preventative Care:
Preventative Care is a 100% benefit, but subject to the Plan's limitations. A member and their spouse have a $300.00 benefit available yearly. Eligible dependents have a yearly benefit of $500.00 available.

Dental Care (usual and customary plan):
Dental claims are paid as follows:
-Preventative and diagnostic services are payable at a 100% (cleaning, exams, and bitewings);
-Cleanings and exams are allowed twice in a calendar year. Basic and major services are payable at 80%;
-Fluoride treatments are payable on children up to the age of 19 and can be paid twice per year;
-Full mouth x-rays are allowed once every 36 consecutive months.

There is a $50.00 individual deductible ($150 family maximum) for all Basic and Major services. The calendar year maximum for dental claims is $1,250 per person.

Orthodontics:
Orthodontic services are paid at 50% and have a $1,000.00 lifetime maximum. There is no age limit or deductible for orthodontic services.

Prescription Coverage:
Prescription drug coverage is provided through Caremark and is payable as follows:

Please note: Maintenance medication has a maximum fill limit of three times at the pharmacy. Maintenance medication must then be filled thru mail order.

Caremark can be reached at 1-800-827-6349 or on their website at www.caremark.com.

Vision Care (if applicable to your local):
Vision benefits are available once in a calendar year. EyeMed is the vision network. If you choose to go out of the EyeMed vision network, claims should be mailed to the fund office and are payable as follows:

EyeMed providers can be located by calling 800-334-7591 or on their website at www.eyemedvisioncare.com.