How to File a Claim

Filing Claims Other than Major Medical Claims

Depending on the type of claim you have (death or dismemberment, medical, dental, vision, etc.), there are different requirements for filing a claim. This section provides more detail regarding how to file a claim.

If you need copies of your claim for your records, you should make them before submitting your claim. The Fund Office does not provide copying services. You are responsible for maintaining your own records. The following claim forms can be downloaded:

• Major Medical Claim Form
  
  
• Optical Claim Form
  
  
• Delta Dental Form
  
  
• Claim for Hearing Aid Benefit
  
  
• Weekly Accident and Sickness Disability Benefit Forms
  

Death Benefit or Accidental Death and Dismemberment Benefit Claims

To receive the Death Benefit or Accidental Death and Dismemberment Benefits, you or your Beneficiary must contact the Fund Office and follow the claim procedures in effect at the time of your claim. No claim form is required, but for:

• Death Benefits, your Beneficiary must submit a death certificate; and
  
  
• Dismemberment Benefits, you must submit a letter from your Doctor.
  

Generally, you must submit the required information within two years of the date of death or date of loss.

The Fund will notify you of its decision on your claim within 60 days of the date it receives your claim. This timeframe may be extended if the Fund Office needs additional information to process your claim. In that case, the Fund Office will notify you of the additional information that is needed and you will be given 45 days to provide the information. If you do not provide the information, the Fund Office will decide your claim on the basis of the information that has been provided and your claim may be denied.

If the claim is approved, the Fund Office will send a check in the applicable amount to you or to your Beneficiary.

Prescription Drug Benefits Claims

The Prescription Drug Benefits cover your short-term prescription needs through a Retail Pharmacy Network and long-term prescription needs through a Mail Order Prescription Drug Service.

Retail Pharmacy Network

The Retail Pharmacy Network is offered through CVS Caremark Prescription Service.If an acute medication (immediate treatment) has been prescribed for you, you should have the prescription filled at a participating network pharmacy. You must present the Prescription Drug card or other form of identification to the pharmacist and pay the applicable co-payment and deductible to the pharmacy. You will receive the prescription and no paperwork will be required. CVS Caremark will pay the balance of the cost of the prescription directly to the pharmacy.

If you do not use a participating network pharmacy, you are responsible to pay the entire cost of the prescription.You must complete a claim form and submit it to CVS Caremark in order to be reimbursed for covered Prescription Drugs obtained through a non-network pharmacy. Your reimbursement will be equal to the amount the Fund would have been charged for the prescription by the network pharmacy at the negotiated pharmacy rate, less the co-payment and deductible (if applicable).

The claim form should be sent to:

CVS Caremark Claims Dept.

P.O. Box 52196

Phoenix, Arizona 85072-2196

You may obtain a CVS Caremark Claim Form by contacting CVS Caremark at 1-800-776-1465, visiting their website at www.caremark.com or by contacting the Fund Office.

Mail Order Prescription Drug Service

The mail order Prescription Drug service is administered by CVS Caremark. If a maintenance medication (long-term treatment) has been prescribed for you, you should have the prescription filled through the mail order program. To order a prescription from the CVS Caremark Mail Order Prescription Drug Service, complete a CVS Caremark mail order form, enclose the prescription prepared by your Doctor, and send it to CVS Caremark.See pages 48-49 for more information about the mail order prescription drug service administered by CVS Caremark.

Wellness Expense Benefit Claims

To receive the Wellness Expense Benefit, your Physician must submit a claim to Blue Cross Blue Shield of Illinois with a diagnosis code indicating the need for a general or routine physical exam and related expenses including certain diagnostic testing covered by the Plan.

Dental Benefit Claims

If you go to a Delta Dental participating Dentist, the Dentist will submit a claim form directly to Delta Dental and you will only be responsible for any deductibles, copayments, and non-covered charges. If you go to a non-participating Dentist, you may be required to pay the Dentist his or her fees, and then file a claim with Delta Dental for reimbursement under the Dental Plan. You must include any information or proof necessary to process the claim.

Contact Delta Dental for the appropriate dental claim form. Complete the claim form section entitled This Part of Form to be Completed by Member.

You must complete a separate claim form for each member of your family who is filing for benefits – even if two people are filing for the same type of benefits. In addition, you must complete and file a new claim form each and every time a non-network claim is submitted. Be sure to give all information requested on the form and check all appropriate boxes. Delta Dental does not require their own claim form; the standard ADA (American Dental Association) claim form is acceptable.

Optical Expense Benefit Claims

To receive the Optical Expense Benefit, you must file a claim form with the Fund Office. Contact the Fund Office for the appropriate claim form. Complete the front of the claim form in the section entitled This Part of Form to be Completed by Member. You must complete and file a separate claim form for each member of your family who is filing for benefits – even if two people are filing for the same type of benefits. In addition, you must complete and file a new claim form each and every time a claim is submitted. Be sure to give all information requested on the form and check all appropriate boxes.

You must send an itemized bill with your claim form (or proof requested that is reasonably required to process such claims). You must pay the bill in full before the Fund will reimburse you for the Optical Expense Benefit. Have your optometrist complete the appropriate portion of the claim form and return the completed claim form to the Fund Office. Once approved, a check for the appropriate amount will be forwarded to you.

Hearing Aid Expense Benefit Claims

To receive the Hearing Aid Expense Benefit, you must file a claim form with the Fund Office. If you use a HearPO Provider, your Provider will file your claim for you. If you need a claim form, contact the Fund Office for the appropriate claim form. Complete the claim form section entitled This Part of Form to be Completed by Member.

You must complete and file a separate claim form for each member of your family who is filing for benefits – even if two people are filing for the same type of benefits. In addition, you must complete and file a new claim form each and every time a claim is submitted. Be sure to give all information requested on the form and check all appropriate boxes.

You must send an itemized bill with your claim or any information or proof requested that is reasonably required to process such claims. You must pay the bill in full before the Fund will reimburse you for the Hearing Aid Expense Benefit. Have your doctor or audiologist complete the appropriate portion of the claim form and return the completed claim form to the Fund Office. Once approved, a check for the appropriate amount will be forwarded to you.