CHURCHWIDE HEALTHCARE - Pension Fund

HURCHWIDEHEALTHCARE
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CONTENT
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Welcome/Our Partners
Membership Guidelines
Highmark BCBS Program
Summary of Medical Benefits
Prescription Drug Overview
Prescription Drug Details
Flexible Spending Accounts (FSA) Overview
Voluntary Dental Program
Employer Paid Dental Program
Vision Benefits
Legal Updates
Medicare Part D Notice
The benefit information included in this guide is summary information. It is not intended
to be a complete description of the benefit plans. That description, which contains coverage
and exclusion information, is contained in the Summary Plan Descriptions (SPD). If a
discrepancy exists, the SPD will prevail.
PAGE 1

Benefits Guide 2011
Thank you for your interest in the Churchwide Healthcare.
The Christian Church Health Care Benefit Trust (CCHCBT) and the Pension Fund have been offering health
coverage (Churchwide Healthcare) since 1972 to clergy and employees of the ministries of the Stone-Campbell
Tradition, including the Christian Church (Disciples of Christ), Church of Christ, and North American Christian
Convention. We offer three medical plan options (covering prescription drugs and vision); two fully – insured
dental plans, and flexible spending account administration.
The Christian Church Health Care Benefit Trust, with the Pension Fund of the Christian Church as Trustee,
manages these programs on behalf of the General Assembly of the Christian Church (Disciples of Christ).
Together with our partner vendors, the Christian Church Health Care Benefit Trust strives to offer
comprehensive, affordable, and portable coverage to clergy and employees of the Stone-Campbell Tradition.
Our partner vendors are:
Medical & Flexible Spending
Accounts Benefit Plans
Highmark Blue Cross Blue Shield
1.800.648.4078
www.highmarkbcbs.com
Preferred Provider Network
Blue Card PPO Network
1.800.648.4078
www.highmarkbcbs.com
Pharmacy Benefit Manager
Medco Health Solutions
1.800.818.0093
www.medcohealth.com
Vision Benefits
VSP
1.800.877.7195
www.vsp.com
Dental Benefit
Delta Dental of Indiana, Inc.
1.800.524.0149
www.deltadentalin.com
PAGE 2

Membership Guidelines
Who is eligible for coverage?
In order to particpate in the Churchwide Healthcare program, you must be a compensated staff member of an eligible
organization. Eligible organizations include Christian Church (Disciples of Christ), affiliated non-profit organizations
and other churches that share a heritage from the Stone-Campbell movement. Eligible staff includes: ministers, church
support staff, missionaries, K-12 Christian school personnel, and non-profit Christian college and university employees.
Specific eligibility rules are determined by each individual entity/organization.
If you qualify as an eligible staff member, you can also cover your eligible dependents. Eligible dependents include:
Spouse/Domestic Partner
Children under 26 years of age, including:
Newborn Children
Stepchildren
Children legally placed for adoption
Legally adopted children or children for whom the employee’s spouse is the child’s
legal guardian
Children awarded coverage pursuant to an order of court
Children over age 26 who are not able to support themselves due to mental retardation, physical
disability, mental illness or developmental disability.
Making enrollment changes during the year
In most cases, your benefit elections remain in effect for the entire plan year. During each annual enrollment period, you
will have the opportunity to review your benefit elections and make changes for the coming year.
Certain coverages allow limited changes to elections during the year. These benefits include the medical, dental and
vision plans. Under these benefits, you may only make changes to your elections during the year if you have a change in
family status. Family status changes include:
Marriage, divorce or legal seperation
Gain or loss of an eligible dependent for reasons such as birth, adoption, court order, disability,
death, marriage, or reaching the dependent child age limit
Changes in your spouse’s employment affecting benefit eligibility
Changes in your spouse’s benefit coverage with another employer that affects benefit eligibility
The change to your benefit elections must be consistent with the change in family status. For example, if you gain a new
dependent due to birth, you may only change your benefit elections to add that dependent. In this case, coverage for
other dependents cannot be changed.
You have 30 days from the date of a change in family status to complete an enrollment change form and return it to
Michael Porter, Director of Health Services. Otherwise, you must wait until the next annual enrollment period to make a
change to your elections. Your elections will become effective the first of the following month, with the exception of a
change due to birth or adoption.
PAGE 3

Highmark BCBS Medical Program
About your Churchwide Healthcare
coverage
Welcome to Churchwide Healthcare (CWHC) coverage
through Christian Church Healthcare Benefit Trust
(CCHCBT). CCHCBT has contracted with Highmark BCBS
to act as Third-Party Administrator of the benefits program,
which gives you access to the BCBS system, one
of the most widely recognized and accepted throughout
the United States. For decades, the nationwide
BCBS family of independent plan providers has offered
members innovative health coverage designed to meet
their needs. You will be covered through the CWHC PPO
plan administered by Highmark BCBS. No matter where
you live in the United States, you may take advantage
of the expansive provider networks and discounts
arranged by the PPO plans around the country. In most
cases, you should not have to file claim forms or pay
anything except your co-payments, deductibles, etc.,
in advance. This guide explains your coverage through
CWHC and the PPO program. For more information,
such as details about how we cover a particular service
or prescription drug, please read your contract or use
one of the sources located in the front of this guide.
How does my medical plan work?
You pay less out-of-pocket if you use the physicians,
hospitals, and other health care providers that participate
in the BCBS PPO network. While you don’t need
referrals to visit specialists, you receive the highest
level of benefits when you use Preferred Providers. In
some instances, such as hospital admissions and home
healthcare services, Highmark BCBS can require prior
approval. In other words, Highmark BCBS must approve
the need for the care before you seek it, or they may
choose not to pay for such care.
To find preferred providers
(in-network):
Visit the www.highmarkbcbs.com web site
and click on “Find a Physician or Facility.”
Call 1-800-648-4078 to find out if the
provider you select is Preferred.
(Remember, you will reach your out-of-pocket maximum
quicker when you use Out-of-Network Providers.
Further, there are separate deductibles and out of pocket
limits for Out-of-Network medical services.) The medical
summary of benefits in the booklet shows a comparison
between benefits when you use In-Network
Providers and benefits when you use Out-of-Network
Providers. Also, keep in mind that your health plan pays
the Allowed Price for services and supplies. In-Network
Providers agree to accept the Allowed Price as payment
in full. When you use Out-of-Network Providers, you
must pay the difference between the Allowed Price and
the provider’s charge. Benefits for most services require
that you pay a deductible each year for In-Network
Providers’ services and Out-of-Network Providers’ services.
Once you have met your deductible, you share
the cost of your care through coinsurance. Deductible
and out-of-pocket amounts do not cross apply. Once
again, your coinsurance percentage amount for Out-of-
Network Providers is higher than the one for In-Network
Providers. You need only pay the deductible and coinsurance
until you meet your out-of-pocket maximum
for the year.
PAGE 4

Summary of Medical Benefits
Benefit Category
PPO Medical Plan Benefit Summaries
In-Network
PPO1 PPO2 PPO HDHP
Benefit Period Calendar Year Calendar Year Calendar Year
Deductible: Individual $500 $1,000 $2,500
Deductible: Family $1,500 $3,000 $5,000
Payment Level/Coinsurance 80% after deductible until out-of-pocket is met, then 100%
Out-of-Pocket (OOP) Maximums: Individual $3,000 $4,500 $6,050
Out-of-Pocket (OOP) Maximums: Family $6,000 $9,000 $12,100
Deductible included in OOP Maximum No No No
Lifetime Maximum
Unlimited
Physician & Specialist Office Visits
80% after deductible
Adult Preventive Care - Routine physical exams
100%; deductible does not apply
Adult Preventive Care - Routine gynecological exams including
a Pap Test
Adult Preventive Care - Mammograms, as required
Pediatric Preventive Care - Routine physical exams
Pediatric Preventive Care - Immunizations
Emergency Room Services
Ambulance
Hospital Expenses - Inpatient
Hospital Expenses - Outpatient
Hospital Expenses - Maternity
Infertility Counseling, Testing & Treatment
Medical/Surgical Expenses (Except Office Visits)
Spinal Manipulations
Diagnostic Services (Lab, X-Ray & other tests)
Physical Medicine (Acupuncture included)
Occupational/Speech Therapy
Durable Medical Equipment, Orthotics and Prosthetics
Skilled Nursing Facility Care
Home Healthcare
Private Duty Nursing
Hospice
Mental Health/Substance Abuse - Impatient
Mental Health/Substance Abuse - Outpatient
Precertification Requirements
100%; deductible does not apply
100%; deductible does not apply
100%; deductible does not apply
100%; deductible does not apply
80% after $100 copayment & deductible; 80% after deductible
80% after deductible
80% after deductible
80% after deductible
80% after deductible
80% after deductible
80% after deductible
80% after deductible
Combined Limit: 20 visits per calendar year
80% after deductible
80% after deductible
Combined Limit: 20 visits per calendar year
80% after deductible
Combined Limit: 20 visits per calendar year
80% after deductible
80% after deductible
Combined Limit: 120 visits per calendar year
80% after deductible
Combined Limit: 40 visits per calendar year
80% after deductible
80% after deductible
Combined Limit: 180 days per lifetime
80% after deductible
Combined Limit: 30 days/calendar year
80% after deductible
Combined Limit: 30 visits/calendar year
Performed by member*
PAGE 5

Prescription Drug Program Overview
Prescription Drug Program
The CCHCBT, through its partnership with Medco, a
Pharmaceutical Benefit Manager, has a tiered prescription
drug program. That means that you pay the lowest
co-payments when you use tier 1 (generic) drugs.
Below is the co-payment structure at retail pharmacies
for a 30-day supply:
Annual Deductible: $50 Individual; $100 Family
Tier 1 (Generic): $10
Tier 2 (Brand Formulary): 20%
(min. $25-max. $75)
Tier 3 (Brand Non-Formulary): 50%
(min. $4O-max. $120)
When you go to in-network pharmacies, you will be
responsible for paying the copay or coinsurance - nothing
more. The pharmacy will bill Medco for the left-over
amount. As you can see, you will pay the lowest copay
if you use a generic drug. Make sure to ask your pharmacist
if a generic alternative is available for the brandname
drug you are prescribed.
You must use pharmacies that are in Medco’s network
to receive the benefit levels above. Over 90% of pharmacies
nationwide currently belong to this network.
Should you use an out-of-network pharmacy, you will
be responsible for the co-pay listed above plus 20% of
the remaining cost of the drug.
The plan provides for 3 refills of medication at a retail
pharmacy. After this, the plan will require you to pay an
additional cost, unless you have this medication filled
using Medco Mail Pharmacy.
Wouldn’t you rather pay $4 for
your prescription?
Did you know that Wal-Mart offers over 300 different
drugs at only $4 per prescription fill or refill (up to a
30-day supply or 60 pill maximum). The program is
available at all Wal-Mart, Sam’s Club and Neighborhood
Market pharmacies. A similar program is also offered
through Target stores.
Brand Formulary-Name Drugs
What is a brand-name drug?
A brand-name druge is a prescription drug that is marketed
under a proprietary, trademark-protected name.
What is a Tier 2 Drug?
A Tier 2 Drug is a “preferred” brand-name drug. The
list of these preferred drugs is created by Medco, your
pharmacy vendor. Many factors are taken into account
when deriving the list, such as the utilization of the
drugs, the cost, and the therapeutic class to name a few.
What is important to know is that Tier 2 Prescription
Drugs are less expensive than Tier 3 Prescription Drugs.
Tier 3 are non-preferred and have the highest coinsurance
level attached to them.
Where can I find the Formulary Drug List?
The Formulary Drug list is updated quarterly to ensure
that newer, more effective drugs are on it. Drugs automatically
come off the list when generic alternatives
become available. To get the most updated formulary
list, register at www.medco.com. Once there, you can
download the formulary listing or search for a medication
by name.
You may want to print off the formulary list and take
it with you to your next doctor’s appointment. If your
doctor has the list, he or she can be sure to prescribe
you a preferred drug. Make sure you take the most
updated list as it is updated quarterly.
PAGE 6

Prescription Drug Program Details
Mandated Generics
For Non-Preferred drugs, including non-sedating antihistamines
(Allegra®, Clarinex®, Zyrtec®, etc.) or if you
purchase a brand medication when a generic is available,
you will pay your copay plus the difference in cost
between the brand and the generic.
Medco By Mail Pharmacies
Over 6 million members enjoy the convenience and
savings of having their long-term medications (maintenance
medications, those taken for three months or
more) delivered to their home or office. Medco by Mail
advantages include:
Get up to a 90 day supply (compared with a typical
30 day supply at retail) of each covered medication
for just one mail order payment.
Tier 1 (Generic): $20
Tier 2 (Brand Formulary): 20%
(min. $60-max. $180)
Tier 3 (Brand Non-Formulary): 50%
(min. $100-max. $300)
Specialty Medications
Specialty medications are drugs that are used to treat
complex conditions, such as cancer, growth hormone
deficiency, hemophilia, hepatitis C, immune deficiency,
multiple sclerosis and rheumatoid arthritis. Medco’s
specialty pharmacy, Accredo Health Group, Inc. is
composed of therapy-specific teams that provide an
enhanced level of personalized service to patients with
special therapy needs. By ordering your specialty medications
through Accredo, you can receive:
Personalized counseling from our dedicated team
of registered nurses and pharmacists.
Expedited, scheduled delivery of your medications
at no extra charge.
Complimentary supplies, such as needles and
syringes.
Refill reminder calls.
Safety checks to help prevent potential drug interactions.
Order refills online, by mail or by phone-anytime
day or night. To order online, register at www.
medco.com. Refills are usually delivered within three
to five days after Medco receives your order. You can
also have your doctor fax your prescriptions. Ask
your doctor to call 1-888-327-9791.
Choose a convenient payment option-Medco
offers two safe, automatic options for prescription
orders. You can use e-check to have payments automatically
deducted from your checking account, or
you can use AutoCharge to have payments automatically
charged to the credit card of your choice.
For more information, visit www.medco.com or call
member services at 1-800-418-9925.
PAGE 7

Flexible Spending Accounts Overview
What is a healthcare Flexibile
Spending Account (FSA)?
A healthcare flexible spending account provides you
the opportunity to benefit from the tax savings available
by setting aside money to pay for future health
care expenses on a pre-tax basis. Healthcare flexible
spending account contributions are not subject to federal
income tax, Social Security taxes, and most state
and local income taxes. Check with your local tax advisor
regarding your state and local income tax laws.
How does the FSA work?
The Christian Church (Disciples of Christ) Flexible
Spending Accounts for Healthcare (“Healthcare FSA”)
allows you to prefund out-of-pocket medical and dental
costs and other qualified medical costs not otherwise
covered through the Churchwide Healthcare.
Qualified expenses may include:
Deductibles
Well Baby Care
Co-payments
Organized Weight Loss Programs
Vision Care (including RK and LASIK)
Dental Care
Hearing Aids and other related expenses
Prescription Drugs
Transportation to receive care
Certain non-covered procedures such
as experimental surgeries
Annual Physicals
Body scanning and Heart scoring
How do I get reimbursed?
You do not need to submit a copy of a cancelled check
or a receipt for a bill that is already paid as proof of
expense. An invoice or copy of an unpaid bill is acceptable
since the program operates on an incurred date.
We will look at the date the service was received to
determine if it is eligible for the program year.
Dependent Care Spending
Account
Day care expenses are covered for the following dependents
while you work (and if married, while your spouse
is at work, is a full-time student or is disabled):
Your children under 13;
Your dependent who is physically or mentally disabled
and incapable of self-care, including your
spouse or child of any age;
Claimed as dependents for income tax purposes, and;
Your dependent parent or other dependent who
spends at least eight hours a day in your home.
Eligible dependent care expenses include those for care
in your home, in a babysitter’s home, or at a licensed
day care
Minimum: $520.00
Maximum: $ 5,000.00 (or $2,500.00 if you are married
and file separate income tax returns)
PAGE 8

Flexible Spending Account Overview
Use it or lose it
It is important to accurately estimate your expenses
and only elect an annual contribution to cover expected
claims, because IRS rules require that any money left
in your Health Care FSA account be forfeited. However,
as long you are a participant you do have until March
31 to submit any eligible expenses you incur between
January 1 and March 15 of the next year.
How do I submit a claim?
When you have an eligible expense to be reimbursed
from your Health Care FSA, you can file a claim by completing
a Flexible Spending Account Claim Form and
submitting it, and proof of expense, to Highmark BCBS:
Account Service Center
P.O. Box 22130
Pittsburgh, PA 15222-0130
Fax: 866-309-8906
This form is also available on the Disciples Health website:
www.discipleshealth.org
Can medical and dental premiums
be reimbursed?
No, the IRS does not allow reimbursement of monthly
insurance premiums through a flexible spending
account.
When may I enroll?
You must enroll within 31 days of your hire date or
along with enrollment in the Churchwide Health Care
Program. If you do, your contributions take effect as
of the date you enroll. If you don’t enroll within the
prescribed time frames, you must wait until the next
annual enrollment to enroll.
Annual enrollment takes place each year. During this
time, you can start, stop, or change the amounts you are
contributing to the flexible spending account(s). Any
elections you make, however, take effect on January
1 and remain in effect through December 31 of that
calendar year.
The before-tax advantage
By contributing to a Healthcare FSA, you authorize a
congregation or church-related organization to set
aside a certain amount from your pay before taxes are
withheld. Since you are taxed only on the cash salary
amount remaining in your paycheck, this reduces your
taxable wages. Lower taxable income means that you
pay less in taxes.
Your Health Care FSA contributions are not subject to:
Federal Income Taxes;
Social Security (FICA or SECA) taxes, and;
Most state and local (including county) income
taxes. (Rules vary, and state and local taxes are subject
to frequent changes.)
PAGE 9

Voluntary Dental Program
Dental PPO Plan - Delta Dental (voluntary)
Delta Dental has one of largest networks of dentists in
the country through DeltaPremier USA. With the PPO
dental plan, you may see any dentist that you choose.
However, you have access to discounted charges by
utilizing network providers.
You will receive your Dental ID card in the mail within
three weeks of your enrollment.
To locate participating dentists, go to www.deltadental.
com or call1-800-524-0149.
PPO Dentist Premier Dentist Non-Participating
Dentist
Plan Pays Plan Pays Plan Pays*
Diagonstic & Preventive
Diagnostic & Preventive Services:
includes exams, cleanings and flouride
100% 100% 100%
Brush Biopsy: to dectect oral cancer 100% 100% 100%
Bitewing Radiographs: bitewing X-rays 100% 100% 100%
Basic Services
Space Maintainers: appliances to prevent
tooth movement
50% 50% 50%
Emergency Palliative Treatment:
to temporarily relieve pain
50% 50% 50%
Sealants: to prevent decay of permanent
teeth
50% 50% 50%
All Other Radiographs: other x-rays 50% 50% 50%
Minor Restorative Services: fillings &
crown repair
50% 50% 50%
Endodontic Services: root canals 50% 50% 50%
Periodontic Services: to treat gum disease 50% 50% 50%
Oral Surgery Services: extractions & dental
surgery
50% 50% 50%
Other Basic Services: misc. services 50% 50% 50%
Relines & Repairs: bridges & dentures 50% 50% 50%
Major Services
Major Restorative Services: crowns 25% 25% 25%
Prosthodontic Services: includes bridges,
implants & dentures
25% 25% 25%
Orthodontic Services
Orthodontic Services: includes braces 50% 50% 50%
Orthodontic Age Limit up to age 19 up to age 19 up to age 19
*When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental’s
Nonparticipating Dentist Fee that will be paid for those services. This Nonparticipating Dentist Fee may be less than what your dentist
charges, which means that you will be responsible for the difference.
PAGE 10

Voluntary Dental Program
Covered Services
Oral exams (including evaluations by a specialist) are
payable twice per calendar year.
Prophylaxes (cleanings) are payable twice per calendar
year.
Fluoride treatments are payable once per calendar
year for people up to age 14.
Bitewing X-rays are payable once per calendar year
and full mouth X-rays (which include bitewing
X-rays) are payable once in any five-year period.
Sealants are only payable once per tooth per lifetime
for the occlusal surface of first permanent molars
up to age nine and second permanent molars up
to age 14. The surface must be free from decay and
restorations.
Crowns, inlays, and substructures are payable once
per tooth in any seven-year period.
Deductible
$50 deductible per person total per benefit year. The
deductible does not apply to diagnostic services, prophylaxes
(cleanings), fluoride, brush biopsy, bitewing
x-rays, and orthodontic services.
Dental Care Around the World
Having Delta Dental coverage makes it easy for our
enrollees to get dental care almost everywhere in the
world! You can receive expert dental care when you
are outside of the United States through our Passport
Dental program. This program gives you access to
a worldwide network of dentists and dental clinics.
English-speaking operators are available around the
clock to answer questions and help you schedule care.
For more information, check our web site or contact
your benefits representative to get a copy of our
Passport Dental information sheet.
Composite resin (white) restorations are Covered
Services on posterior teeth.
Porcelain crowns are optional treatment on posterior
teeth.
Full and partial dentures are payable once in any
seven-year period.
Bridges and substructures are payable once in any
seven-year period.
Implants and implant related services are payable
once per tooth in any seven-year period.
People with certain high-risk medical conditions
may be eligible for additional prophylaxes (cleanings)
or fluoride treatment. The patient should talk
with his or her dentist about treatment.
Maximum Payment
$1,000 per person total per benefit year on all services
except orthodontics. $500 per person total per lifetime
on orthodontic services.
PAGE 11

Employer Paid Dental Program
Dental PPO Plan - Delta Dental (employer paid)
What is DeltaPremier USA?
DeltaPremier USA is a carefully managed fee-for-service
program administered by Delta Dental. “Fee-for-service”
means that the dentist charges a fee for each service
performed, then sends a claim to Delta Dental. Delta
Dental then pays a certain percentage for each covered
service. With DeltaPremier USA, you are likely to lower
your out-of-pocket costs by going to a DeltaPremier
participating dentist. That is because participating dentists
agree to accept their fee or Delta Dental’s UCR fee,
whichever is less, as full payment for covered services.
More than 108,000 dentists throughout the United
States and its territories participate in DeltaPremier
USA.
PPO Dentist Premier Dentist Non-Participating
Dentist
Plan Pays Plan Pays Plan Pays*
Diagonstic & Preventive
Diagnostic & Preventive Services:
includes exams, cleanings, flouride &
100% 100% 100%
space maintainers
Emergency Palliative Treatment:
to temporarily relieve pain
100% 100% 100%
Sealants: to prevent decay of permanent
teeth
100% 100% 100%
Radiographs: x-rays 100% 100% 100%
Basic Services
Minor Restorative Services: fillings &
crown repair
80% 80% 80%
Endodontic Services: root canals 80% 80% 80%
Periodontic Services: to treat gum disease 80% 80% 80%
Oral Surgery Services: extractions & dental
surgery
80% 80% 80%
Other Basic Services: misc. services 80% 80% 80%
Major Services
Major Restorative Services: crowns 50% 50% 50%
Relines & Repairs: bridges & dentures 50% 50% 50%
Prosthodontic Services: includes bridges,
implants & dentures
50% 50% 50%
Orthodontic Services
Orthodontic Services: includes braces 50% 50% 50%
Orthodontic Age Limit up to age 19 up to age 19 up to age 19
*When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental’s
Nonparticipating Dentist Fee that will be paid for those services. This Nonparticipating Dentist Fee may be less than what your dentist
charges, which means that you will be responsible for the difference.
PAGE 12

Employer Paid Dental Program
Covered Services
Oral exams (including evaluations by a specialist) are
payable twice per calendar year.
Prophylaxes (cleanings) are payable twice per calendar
year.
Fluoride treatments are payable twice per calendar
year for people up to age 19.
Bitewing X-rays are payable once per calendar year
and full mouth X-rays (which include bitewing
X-rays) are payable once in any five-year period.
Sealants are only payable once per tooth per lifetime
for the occlusal surface of first permanent molars
up to age nine and second permanent molars up
to age 14. The surface must be free from decay and
restorations.
Composite resin (white) restorations are Covered
Services on posterior teeth.
Porcelain crowns are optional treatment on posterior
teeth.
Deductible
$50 deductible per person total per benefit year limited
to a maximum deductible of $150 per family per benefit
year. The deductible does not apply to diagnostic and
preventive services, emergency palliative treatment,
x-rays, sealants and orthodontic services.
Dental Care Around the World
Having Delta Dental coverage makes it easy for our
enrollees to get dental care almost everywhere in the
world! You can receive expert dental care when you
are outside of the United States through our Passport
Dental program. This program gives you access to
a worldwide network of dentists and dental clinics.
English-speaking operators are available around the
clock to answer questions and help you schedule care.
For more information, check our Web site or contact
your benefits representative to get a copy of our
Passport Dental information sheet.
Implants and implant related services are payable
once per tooth in any seven-year period.
People with certain high-risk medical conditions
may be eligible for additional prophylaxes (cleanings)
or fluoride treatment. The patient should talk
with his or her dentist about treatment.
Maximum Payment
$1,200 per person total per benefit year on all services
except orthodontics. $1,000 per person total per lifetime
on orthodontic services.
PAGE 13

Vision Benefits
Vision - Vision Service Plan (VSP)
Your vision coverage will be provided by Vision Service
Plan (VSP) with national and local network access. With
VSP doctors, you’ll enjoy quality, personalized care. Your
VSP doctors will get to know you and your eyes, helping
you keep them healthy year after year. Besides helping
you see better, routine eye exams can detect symptoms
of serious conditions such as glaucoma, cataracts, diabetes,
and even tumors.
Effortless Benefits
Choose a VSP doctor at www.vsp.com or call 1-800-877-
7195.
Make an appointment and tell the doctor you are a VSP
member.
That’s it! No ID cards or filling out claim forms.
Your Coverage from a VSP Doctor
Exam covered in full
Every plan year
Prescription Eyewear Discounts
Lens
Frame
Contact Lens Care
20% discount when complete pair of glasses are purchased.
20% discount when complete pair of glasses are purchased.
15% discount off the contact lens fitting and evaluation exam.
This exam is in addition to your vision exam to ensure proper fit
of contacts.
Extra Discounts and Savings
Vision Correction Discounts
Prescription Glasses
Contacts
20% off additional complete pairs of prescription glasses.
15% off cost of contact lens exam (fitting & evaluation).
20% off additional complete pairs of prescription glasses.
Prescription Glasses*
*Available from the same VSP doctor who provided your eye exam
within the last 12 months
15% off cost of contact lens exam (fitting & evaluation)
Contacts*
*Available from the same VSP doctor who provided your eye exam
within the last 12 months
Your Copays Exam $20
PAGE 14

Legal Updates
The Women’s Health and Cancer
Rights Act
The Women’s Health and Cancer Rights Act requires
group health plans that provide coverage for mastectomy
and certain reconstructive services. This law also
requires that written notice of the availability of the
coverage be delivered to all plan participants upon
enrollment and annually thereafter. This language
serves to fulfill that requirement for this year. These
services include:
Reconstruction of the breast(s) upon which the
mastectomy has been performed;
Surgery/reconstruction of the other breast to
produce a symmetrical appearance;
Prostheses; and
Treatment for physical complications during all
stages of mastectomy, including Iymphedemas.
In addition, the plan may not:
Interfere with a participant’s rights under the plan to
avoid these requirements; or
Offer inducements to the health care provider, or
assess penalties against the provider, in an attempt
to interfere with the requirements of the law.
HIPAA Special Enrollment Rights
If you are declining or have declined enrollment for
yourself or your dependents (including your spouse)
because of other health insurance coverage, you may
in the future be able to enroll yourself or your dependents
in this plan, provided that you request enrollment
within 30 days after your other coverage ends.
You may also be able to enroll yourself or your dependents
in the future if you or your dependents lose health
coverage under Medicaid or your state’s Children’s
Health Insurance Program, or become eligible for state
premium assistance for purchasing coverage under a
group health plan, provided that you request enrollment
within 60 days after that coverage ends or after
you become eligible for premium assistance.
In addition, if you have a new dependent as a result of
marriage, birth, adoption, or placement for adoption,
you may be able to enroll yourself and your dependents,
provided that you request enrollment within 30
days after the marriage, birth, adoption, or placement
for adoption.
HIPPA Privacy Notice
Contact Michael Porter, Director of Health Services, for
further details or questions. Churchwide Healthcare
follows all legal requirements with regard to protecting
your Protected Health Information (PHI).
However, the plan may apply deductibles, coinsurance,
and copays consistent with other coverage provided by
the Plan.
PAGE 15

Legal Updates
Newborns & Mothers Health
Protection Act
Federal Law (Newborn’s and Mother’s Health Protection
Act of 1996) prohibits the plan from limiting a mother’s
or newborn’s length of hospital stay to less than 48
hours for a normal delivery or 96 hours for a cesarean
delivery or from requiring the provider to obtain
pre-authorization for a stay of 48 hours or 96 hours,
as appropriate. However, Federal Law generally does
not prohibit the attending provider, after consultation
with the mother, from discharging the mother or her
newborn earlier than 48 hours for normal delivery or 96
hours for cesarean delivery.
Mental Health Parity Act
According to the Mental Health Parity Act of 1996, the
lifetime maximum and annual maximum dollar limits
for mental health benefits under the CCHCBT Group
Medical Plan are equal to the lifetime maximum and
annual maximum dollar limits for medical and surgical
benefits under this plan. However, mental health benefits
may be limited to a maximum number of treatment
days per year or series per lifetime.
Children’s Health Insurance
Program (CHIP) Coverage
Under the Churchwide Healthcare group health plans,
employees and their eligible dependents may enroll
for coverage when they first become eligible for coverage
and annually during Open Enrollment. In addition,
employees and/or their eligible dependents are
allowed to enroll in the group health plan if they experience
a special enrollment event under the Health
Insurance Portability and Accountability Act (HIPAA).
Effective April 1, 2009, the plan rules have changed to
allow you and/or your eligible dependents to enroll for
coverage under a new HIPAA special enrollment opportunity.
If you have any questions or want more information,
please contact Michael Porter, Director of Health
Services at 866-495-7322.
Continuation Required by Federal
Law for You and Your Dependents
Federal law enables You or Your Dependent to continue
health insurance if coverage would cease due
to a reduction of your work hours or your termination
of employment (other than for gross misconduct).
Federal law also enables Your Dependent(s) to continue
health insurance if their coverage ceases due to your
death, divorce, legal separation, or with respect to a
Dependent Child (ren), failure to continue to qualify as
a Dependent. Continuation must be elected in accordance
with the rules of Your Employer’s group health
plan(s) and is subject to Federal law, regulations and
interpretations.
PAGE 16

Medicare Part D Notice
Important Notice about your prescription drug coverage and Medicare
Please read this notice carefully and keep it where
you can find it. This notice has information about your
current prescription drug coverage with Churchwide
Healthcare and about your options under Medicare’s
prescription drug coverage. This information can help
you decide whether or not you want to join a Medicare
drug plan. If you are considering joining, you should
compare your current coverage, including which drugs
are covered at what cost, with the coverage and costs of
the plans offering Medicare prescription drug coverage
in your area. Information about where you can get help
to make decisions about your prescription drug coverage
is at the end of this notice.
There are two important things you need to know about
your current coverage and Medicare’s prescription drug
coverage: Medicare prescription drug coverage became
available in 2006 to everyone with Medicare. You can
get this coverage if you join a Medicare Prescription
Drug Plan or join a Medicare Advantage Plan (like an
HMO or PPO) that offers prescription drug coverage. All
Medicare drug plans provide at least a standard level of
coverage set by Medicare. Some plans may also offer
more coverage for a higher monthly premium.
When can you join a Medicare drug plan?
You can join a Medicare drug plan when you first
become eligible for Medicare and each year from
November through December.
However, if you lose your current creditable prescription
drug coverage, through no fault of your own,
you will also be eligible for a two (2) month Special
Enrollment Period (SEP) to join a Medicare drug plan.
What happens to your current coverage if you
decide to join a Medicare drug plan?
If you decide to join a Medicare drug plan, your current
CCHCBT coverage will not be affected. Your current
coverage pays for other expenses in addition to prescription
drugs. If you enroll in a Medicare prescription
drug plan, you and your eligible dependents will still
be eligible to receive all of your current health and prescription
drug benefits. If you drop your current coverage
and enroll in Medicare prescription drug coverage,
you may enroll back into Churchwide Healthcare’s benefit
plan during the annual enrollment period under
Churchwide Healthcare’s Benefit Plan.
CCHCBT has determined that the prescription drug
coverage offered by the Churchwide Healthcare Health
Plan is, on average for all plan participants, expected
to pay out as much as standard Medicare prescription
drug coverage pays and is therefore considered
Creditable Coverage. Because your existing coverage
is Creditable Coverage, you can keep this coverage and
not pay a higher premium (a penalty) if you later decide
to join a Medicare drug plan.
PAGE 17

Medicare Part D Notice
When will you pay a higher premium (penalty) to join a Medicare Drug Plan?
You should also know that if you drop or lose your current
coverage with CCHCBT and don’t join a Medicare
drug plan within 63 continuous days after your current
coverage ends, you may pay a higher premium (a penalty)
to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable
prescription drug coverage, your monthly premium
may go up by at least 1% of the Medicare base
beneficiary premium per month for every month that
you did not have that coverage. For example, if you go
nineteen months without creditable coverage, your
premium may consistently be at least 19% higher than
the Medicare base beneficiary premium. You may have
to pay this higher premium (a penalty) as long as you
have Medicare prescription drug coverage. In addition,
you may have to wait until the following November to
join.
For more information about this notice or your current
prescription drug coverage ...
Contact Michael Porter, Director of Health Services, at
866-495-7322. NOTE: You’ll get this notice each year.
You will also get it before the next period you can join
a Medicare drug plan, and if this coverage through
CCHCBT changes. You also may request a copy of this
notice at any time.
For more information about your options under medicare
prescription drug coverage ...
More detailed information about Medicare plans that
offer prescription drug coverage is in the “Medicare &
You” handbook. You will get a copy of the handbook
in the mail every year from Medicare. You may also be
contacted directly by Medicare drug plans.
For more information about Medicare prescription
drug coverage:
Visit www.medicare.gov
Call your State Health Insurance Assistance Program
(see the inside back cover of your copy of the “Medicare
& You” handbook for their telephone number) for personalized
help;
Call 1-800-MEDICARE (1-800-633-4227). TTY users
should call 1-877-486-2048.
If you have limited income and resources, extra help
paying for Medicare prescription drug coverage is available.
For information about this extra help, visit Social
Security on the web at www.socialsecurity.gov, or call
them at 1-800-772-1213 (TTY 1-800-325-0778).
Name of Entity/Sender
Christian Church Health Care Benefit Trust
Contact
Michael Porter; Director of Health Services
Address
130 East Washington Street, Indianapolis, IN 46204
Phone Number
866-495-7322
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be
required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage
and, therefore, whether or not you are required to pay a higher premium (a penalty).
PAGE 18

Terms You Should Know
Coinsurance
The percentage of eligible expenses you and the plan
share. The exact coinsurance depends on the plan your
employer offers.
Co-payment
The fixed, up-front dollar amount you pay for certain
covered expenses. Co-payment amounts do not apply
toward your deductible or coinsurance, and they do not
accumulate toward the out-of-pocket maximum.
Deductible
Intial amount you must pay each benefit year for
covered services before the plan begins to provide
benefits.
Flexible Savings Account (FSA)
An account allowed under Section 125 of the tax code
to allow employees to set aside funds on a pre-tax basis
to reimburse the member for IRS approved medical,
dental and vision expenses not covered by Churchwide
Healthcare. The catch is the “use it or lose it” clause,
which means if you do not exhaust your account
in the calendar year, then remaining funds remit to
Churchwide Healthcare.
High Deductible Health Plan (HDHP)
A High Deductible Health Plan is defined as a health
plan that does not have deductible less than $1200
for individual/$2400 for family (not to exceed $6050
individual/$12,100 for family). May be used with either
a Health Reimbursement Account or Health Savings
Account for approved non-covered medical expenses.
Health Insurance Portability and
Accessibility Act (HIPAA)
This law has two affects on Churchwide Healthcare. On
the one hand, it mandates the issuance of Certificates of
Credible Coverage to help offset pre-existing condition
time periods. More recently, it has been updated to
protect personal health information (PHI) from being
distributed to disinterested parties and to insure the
privacy of our members.
Health Reimbursement Account (HRA)
Health Reimbursement Accounts are set up by
employers to reimburse employees for IRS approved
medical, dental and vision expenses not covered by
Churchwide Healthcare, usually paired with the High
Deductible Health Plan.
Health Savings Account (HSA)
Health Savings Accounts are money market like
accounts that can be set up with contributions from
either the employer, employee or both. Funds go
into these accounts tax-free and as long as the funds
are used for IRS approved medical, dental and vision
expenses not covered by Churchwide Healthcare
High Deductible Health Plans, are withdrawn tax free.
Funds are owned by the employee, regardless of the
contributor, and can be carried over year to year.
In-Network Care
Care you receive from in-network physicians, specialists,
hospitals. rehabilitation centers, labs and other
healthcare providers that have signed an agreement
with their local Blue Cross and Blue Shield plan. Innetwork
providers accept the allowable charge as
payment in full. They also file claims for you. In-network
care is paid at the higher level of benefits.
Out-of-Network Care
Care you receive from healthcare providers who are not
in the network. This care is covered at the lower,. outof-network
level when it is determined to be medically
necessary and appropriate.
Out-of-Pocket Maximum
The amount you pay out of your pocket for eligbile
healthcare expenses before the plan begins to pay 100%
for additional eligible expenses. The out-of-pocket limit
does not include co-payments, deductibles, mental
health/substance abuse expenses, prescription drug
expenses or amounts over the allowable plan charge.
Preferred Provider Organization Program
(PPO)
A program that does not require the selection of a
primary care physician, but is based on a provider
network made up of physicians, specialists, hospitals
and other healthcare facilities. Using this provider
network helps assure members receive coverage for
eligible services.
Patient Protection and Afforadable Care
Act of 2010 (PPACA)
Commonly known as the Health Care Reform Law, this
law is the guiding force of health coverage starting
2011 going forward. Some of the changes already in
place include covering dependents to age 26, no preexisting
condition clauses for children under age 19,
and codifying preventive care services to be covered at
100%.
PAGE 19

Christian Church (Disciples of Christ)
Health Care Benefit Trust
130 E. Washington Street
Indianapolis, IN 46204-3659
Toll-free: 866.495.7322
Phone: 317-634-4504
Fax: 317.634.4071
www.discipleshealth.org