100_07_2016_SPD_ELCA_Medicare-Primary_Health_FINAL

ELCA Medicare-Primary Health Benefits Summary
SUMMARY PLAN DESCRIPTION EFFECTIVE JAN. 1, 2016

About This Document
This plan summary, in conjunction with the ELCA Benefit Program Description, forms the summary plan
description (SPD) for ELCA Medicare-Primary health benefits offered through the ELCA Medical and Dental
Benefits Plan (ELCA Health Plan), effective Jan. 1, 2016. This plan summary describes plan rules and benefits,
while the ELCA Benefit Program Description describes eligibility, enrollment, and how professional and life
changes affect your benefits. Use these two documents together as a reference when you have questions about
your ELCA Medicare-Primary health benefits. Together, these documents replace and supersede all previous
versions. The ELCA Benefit Program Description is available by signing in to myPortico at
PorticoBenefits.org/summaries or contacting the Portico Customer Care Center at mail@PorticoBenefits.org or
800.352.2876.
The plan document of the ELCA Medical and Dental Benefits Plan is the full, legal description of the plan. Your
rights under the plan are governed by the plan document. If this summary is found to be inconsistent with the plan
document, the plan document will be considered the controlling document. A copy of the plan document is
available from the Portico Customer Care Center. Portico reserves the right to change any term of the plan
through the amendment or termination process described later in this summary.
About Portico Benefit Services
For over 25 years, Portico Benefit Services has offered health, retirement, and other benefits designed to enhance
the well-being of those who serve. Because we focus on those who serve through the Evangelical Lutheran
Church in America and other faith-based organizations, we can tailor our benefits to include advantages and
options suited just for our membership. As part of the ministry community and as experienced professionals, we
are qualified to design and manage all aspects of the ELCA’s benefit plans.
Portico serves more than 7,000 congregations and organizations, and more than 50,000 people across the ELCA
during their working years and in retirement — including pastors, associates in ministry, diaconal ministers,
deaconesses, lay employees, retirees, and their family members.
About Our Plans
The ELCA Pension and Other Benefits Program provides health, flexible spending, retirement, disability, and
survivor benefits presented as one comprehensive program to members. Benefit plans are governed and
administered individually through separate plan documents. The Board of Pensions of the Evangelical Lutheran
Church in America, doing business as Portico Benefit Services, maintains the following plans: ELCA Retirement
Plan, ELCA Disability Benefits Plan, ELCA Survivor Benefits Plan, ELCA Medical and Dental Benefits Plan
(which includes the ELCA post-retirement medical benefits obligation), and ELCA Flexible Benefits Plan. We
also maintain three group retirement plans for ELCA-affiliated social ministry organizations — the ELCA Master
Institutional Retirement Plan, the ELCA Retirement Plan for The Evangelical Lutheran Good Samaritan Society,
and the ELCA 457(b) Deferred Compensation Plan. The assets of each plan are held in various trusts and
therefore do not allow one plan to fund a shortfall of another plan. The plans are church plans, as defined in
section 414(e) of the Internal Revenue Code and are not subject to the Employee Retirement Income Security Act
(ERISA). The health and disability plans are self-insured and are not protected through any type of insurance
program. Our ability to pay claims is dependent on continued contributions and market performance. The basic,
supplemental, and dependent life insurance benefits are offered by Securian Life Insurance Company (Securian
Life). Product guarantees are backed by the financial strength and claim paying ability of Securian Life.
Premiums are not guaranteed to remain unchanged. Portico Benefit Services does not assume any responsibility
or liability for the obligations of Securian Life under the insurance policies. Portico Benefit Services is not
affiliated with Securian Life. We reserve the right to change any of the terms of the plans at any time through the
amendment or termination process described in each plan’s summary plan description.

Contents
About ELCA Medicare-Primary Health Benefits ..................................................................................1
Eligibility .............................................................................................................................................................2
Medicare Supplement Benefit...................................................................................................................3
2016 ELCA Medicare Supplement Benefit Chart ...............................................................................................4
Hospital and Medical Claims...............................................................................................................................5
Part A Hospital Care Services..............................................................................................................................5
Part B Medical Services.......................................................................................................................................5
Part B Preventive Services...................................................................................................................................6
Claim Filing Deadline..........................................................................................................................................6
Medical Care Outside the United States ..............................................................................................................6
Coordination of Benefits With Other Coverage ..................................................................................................7
Transitioning From ELCA-Primary Health Benefits...........................................................................................7
Prescription Drug Benefit .........................................................................................................................8
Eligible Prescription Drugs..................................................................................................................................8
Preventive Medications........................................................................................................................................8
Medications Not Covered ....................................................................................................................................9
Formulary...........................................................................................................................................................10
Short-Term Prescriptions...................................................................................................................................10
Maintenance Medications..................................................................................................................................11
Cost Saving and Safety Programs......................................................................................................................11
Hospital Stays ....................................................................................................................................................12
Creditable Coverage...........................................................................................................................................12
If You Have the ELCA Part D Drug Benefit.....................................................................................................12
2016 ELCA Part D Drug Benefit Chart.............................................................................................................13
If You Have the ELCA Prescription Drug Benefit............................................................................................15
2016 ELCA Prescription Drug Benefit Chart....................................................................................................15
Dental Benefit...........................................................................................................................................16
2016 Dental Benefit Chart .................................................................................................................................16
Eligible Dental Expenses...................................................................................................................................17
Pre-Treatment Estimate .....................................................................................................................................17
Preventive Care..................................................................................................................................................17
Basic Dental Care ..............................................................................................................................................17
Major Restorative Care......................................................................................................................................18
Orthodontic Care................................................................................................................................................18
Non-Eligible Expenses.......................................................................................................................................19
Out-of-Network Providers .................................................................................................................................19
Claims Payment .................................................................................................................................................19
Claim Filing Deadline........................................................................................................................................19

Health and Wellness Benefits..................................................................................................................20
ELCA NurseLineSM
............................................................................................................................................20
Health Care Advocacy Team.............................................................................................................................20
Hearing Discount Program ................................................................................................................................20
Mayo Clinic Healthy Living..............................................................................................................................20
SilverSneakers®
Fitness Program.......................................................................................................................21
Contribution Rates...................................................................................................................................22
If You’re Sponsored by an Eligible Employer...................................................................................................22
If You’re Not Sponsored by an Employer .........................................................................................................22
If You’re Self Sponsored ...................................................................................................................................22
2016 Monthly Contribution Rates .....................................................................................................................23
Late Contributions .............................................................................................................................................23
Medicare Part B Reimbursement.......................................................................................................................23
Administrative and Miscellaneous Provisions.......................................................................................24
Appeals Procedure .............................................................................................................................................25
Glossary ....................................................................................................................................................29
Contact Information................................................................................................................................33
Cards for Your Wallet.............................................................................................................................35

Find the most current version of this document, other plan summaries, and the ELCA Benefit Program Description on myPortico at
PorticoBenefits.org/summaries. To learn more, contact the Portico Customer Care Center at mail@PorticoBenefits.org or 800.352.2876.
Page 1
About ELCA Medicare-Primary Health Benefits
ELCA Medicare-Primary health benefits are part of the ELCA Health Plan, which is part of the ELCA
Pension and Other Benefits Program. Also called the ELCA benefit program, it includes:
ELCA Medical and Dental Benefits Plan (ELCA Health Plan)
ELCA Flexible Benefits Plan
ELCA Survivor Benefits Plan
ELCA Disability Benefits Plan
ELCA Retirement Plan
Combined, these plans offer resources to help you and those you care about live well, so you’re better
able to enhance the lives of others.
What ELCA Medicare-Primary Health Benefits Provide
Portico offers a choice of three ELCA Medicare-Primary health benefit options. The options differ by
their monthly contribution rate and Medicare supplement.
Economy — If you rarely visit the doctor or don’t travel outside the United States, the Economy
option’s lower monthly contribution rate may help you save money.
Standard — If you seek regular medical care, the Standard option provides a mid-level
contribution rate.
Premium — If medical costs have been high or you want the option to see doctors who don’t
accept Medicare assignment, consider the Premium option.
Each option includes:
Medicare supplement benefit
Prescription drug benefit
ELCA Part D drug benefit for retired members
ELCA prescription drug benefit for sponsored or on leave from call members and those
living outside the United States
Dental benefit*
Health and wellness benefits
ELCA NurseLineSM
Health Care Advocacy Team
Hearing discount program
Mayo Clinic Healthy Living online website
SilverSneakers®
Fitness Program
*The dental benefit is not available if you opted out of dental coverage in 1996.
ELCA-Primary health benefits are described in a separate document. For a copy of the ELCA-Primary
Health Benefits Summary, visit myPortico at PorticoBenefits.org/summaries or contact the Portico
Customer Care Center at mail@PorticoBenefits.org or 800.352.2876.

Page 2
Eligibility
You’re eligible for ELCA Medicare-Primary health benefits if you meet the program eligibility
requirements as described in the ELCA Benefit Program Description. You (and your family members)
may be eligible for primary health coverage under Medicare and ELCA Medicare-Primary benefits if
you (or your family members) are:
Age 65 or older and retired
Age 65 or older and employed by an organization with fewer than 20 employees
Under age 65 and entitled to Medicare due to disability or end-stage renal disease
You are also eligible for ELCA Medicare-Primary benefits if you are not eligible for Medicare coverage
because you:
Chose to opt out of Social Security, or
Waived participation in all or part of Medicare
In these situations, when a claim is received, your supplement to Medicare Parts A and B claims are
paid assuming what Medicare would have paid if you had Medicare coverage. The plan pays
benefits, subject to the deductible, coinsurance, and out-of-pocket amounts, on the remaining portion of
your claim. You will be responsible for ineligible expenses, the portion that Medicare would have paid,
and deductible and out-of-pocket amounts.
If you’re retired or not sponsored by an employer in the ELCA benefit program — ELCA
Medicare-Primary health benefits offer you and your spouse or eligible same gender partner (ESGP)
(see Glossary) three health benefit options: Economy, Standard, and Premium. See the chart on page 4.
If you’re sponsored by an employer in the ELCA benefit program (that is, you’re employed or
receiving ELCA disability benefits), on leave from call, or living outside the United States — You
and your family are eligible for the Standard health benefit option only. You’re also assigned to the
ELCA Medicare-Primary Standard option if you’re not eligible for Medicare coverage because you:
Chose to opt out of Social Security, or
Waived participation in all or part of Medicare

Page 3
Medicare Supplement Benefit
Administered by Mercer Health & Benefits Administration LLC, the Medicare supplement benefit helps
you pay for eligible Medicare Part A and Part B services not fully paid for by Medicare. For each option
— Economy, Standard, and Premium — Mercer coordinates with Medicare, your primary hospital and
medical coverage. This means the ELCA Medicare supplement benefit helps pay some of the hospital
and medical costs (“gaps”) that Medicare doesn’t cover (like copayments, coinsurance, and deductibles).
If you have both Medicare and the ELCA Medicare supplement benefit:
First, Medicare pays its share of Medicare-approved amounts for your eligible health care claims.
Then, the remaining eligible expenses are sent to Mercer for processing. The plan pays its
portion subject to the benefits described in the chart on the next page.
You pay the ELCA plan’s deductible and coinsurance until you meet the out-of-pocket limit.
Your ELCA Medicare supplement benefit is described in the chart on the next page.
IMPORTANT:
If Medicare does not cover a service, the ELCA Health Plan also won’t cover that service except
as noted in the chart on the next page.
Benefit is subject to change without notice.

Page 4
2016 ELCA Medicare Supplement Benefit Chart
Administered by Mercer
Economy
(Similar to
Medigap L)
Standard
(Portico
Design)
Premium
(Similar to
Medigap F)
You Pay (per person)
ELCA deductible $0 $180 $0
Out-of-pocket annual limit $2,470 $3,500 $0
ELCA Health Plan Pays
Medicare Part A (Hospital)
Part A deductible1
75% 80%2
100%
Part A coinsurance 100% 80%2
100%
Hospice care or skilled nursing
facility coinsurance or copayment
75% 80%2
100%
Blood (first three pints) 75% 80%2
100%
Coinsurance and hospital costs up
to an additional 365 days after
Medicare benefits are used up
100% $0 100%
Medicare Part B (Medical)
Part B deductible1
$0 80%2
100%
Part B coinsurance 75% 80%2
100%
Other
Charges beyond Medicare
approved amount3 $0 $0 100%
Foreign travel and emergency
care
$0
80%2
for services
Medicare covers in
the U.S.; no
lifetime maximum
80% after a $250
deductible; $50,000
lifetime maximum
Eligible expenses after your
annual out-of-pocket limit
100% 100% N/A
1.The 2016 Medicare Part A deductible is $1,288 and Part B deductible is $166. See medicare.gov for more information on
Medicare benefits.
2.After the Standard health benefit option deductible of $180 is met.
3.The approved amount is the amount a doctor or other health care provider is legally permitted to charge for a Medicare-
eligible service.

Page 5
Hospital and Medical Claims
Your provider electronically sends your hospital and medical claims to Medicare first because your
primary coverage is with Medicare. Medicare Part A hospital claims and Part B medical claims are then
sent electronically from Medicare to Mercer using your health insurance claims number. With automatic
claim submission, you don’t submit claims.
After Medicare pays its portion of your eligible expenses, the ELCA Health Plan pays its portion. See
the benefit chart for details. What you pay depends on which ELCA Medicare-Primary option you’re
enrolled in.
Economy — You’re responsible for the Medicare Part A deductible and the ELCA Medicare
supplement coinsurance up to the annual ELCA out-of-pocket limit. The plan pays 100% of
eligible expenses after you reach the annual out-of-pocket limit.
Standard — You’re responsible for the ELCA Medicare supplement annual deductible, then
20% coinsurance up to the annual out-of-pocket limit. The plan pays 100% of eligible expenses
after you reach the annual out-of-pocket limit.
Premium — You pay nothing for Medicare-eligible services in the U.S., even if you receive
Medicare-eligible services from a provider that doesn’t accept Medicare assignment (doesn’t
participate in Medicare). For emergency services received outside the U.S., the plan pays 80% of
eligible expenses up to a lifetime maximum after you meet the foreign care and travel emergency
deductible for this option.
Part A Hospital Care Services
Services that Medicare covers under Medicare Part A include:
Inpatient hospital care
Inpatient skilled nursing facility care
Hospice care (doesn’t include room and board)
Some home health care
NOTE: Your ELCA Medicare-Primary health benefits cover medically necessary inpatient services in a
qualified skilled nursing facility for up to 90 days of continuous care after Medicare becomes your
primary health coverage if the care:
Is authorized by Blue Cross and Blue Shield of Minnesota, and
Begins and continues without interruption while under ELCA-Primary coverage, and
Continues while you transition to ELCA Medicare-Primary coverage
Part B Medical Services
Eligible Medicare Part B services include doctor services, outpatient hospital care, tests, and X-rays.
Part B also covers:
Most medications administered in your doctor’s office
Certain oral cancer medications
Certain agents used with a nebulizer or infusion pump
Diabetes test strips and supplies
Immunosuppressants
Certain antiemetic medications

Page 6
Part B Preventive Services
Medicare Part B also covers certain preventive services. Contact Medicare or review the Medicare &
You book (found at medicare.gov) to learn about Medicare’s benefit for these services. Subject to
Medicare’s age and frequency guidelines, covered preventive services include:
Cardiovascular screening blood tests
Diabetes screening and self-management training
Pelvic exams
Pap tests
Glaucoma screening
Colorectal cancer screenings
Counseling to quit smoking
Mammograms
One-time “Welcome to Medicare” physical exam within the first 12 months you have Part B
Prostate cancer screenings
Influenza, pneumonia, and hepatitis B shots
Bone mass measurements
Alcohol misuse screening and counseling
Depression screening
HIV screening
Obesity screening and counseling
Sexually transmitted diseases screening and counseling
Tobacco cessation counseling
Yearly wellness visit
Claim Filing Deadline
The claim filing deadline is 12 months from the date you incurred the expense. For example, if you incur
expenses on Feb. 12, 2016, you or the provider must file the claim before Feb. 12, 2017. Any claims
filed after the 12-month deadline will be denied.
Medical Care Outside the United States
In most situations, Medicare doesn’t pay for medical care or supplies received outside the United States
or its territories. If you select the Standard or Premium option, and you become ill or injured while
traveling outside the United States, medically necessary care is covered. For benefits, see the chart on
page 4. The Economy option has no foreign emergency coverage.
If you have the Standard or Premium option and you receive care outside the United States, the ELCA
Health Plan will cover expenses that Medicare would normally cover if the services had been received in
the United States, applying the benefits described on page 4. An itemized bill, including the diagnosis
and description of services, translated into English, and the U.S. currency exchange rate in effect at the
time you received care should be sent to Mercer. Keep a copy for your records.

Page 7
Coordination of Benefits With Other Coverage
When you have other valid health coverage in addition to Medicare and ELCA Medicare-Primary health
benefits, coordination of benefits applies. Call the Portico Health Care Advocacy Team to determine
which coverage is primary, secondary, or tertiary. Call Mercer with questions about claims payment
when there is coordination of benefits.
Transitioning From ELCA-Primary Health Benefits
For the year you become eligible for Medicare and ELCA Medicare-Primary health benefits, your out-
of-pocket hospital and medical costs incurred while eligible for ELCA-Primary health benefits don’t
apply to your ELCA Medicare-Primary deductible. You’re no longer eligible to earn wellness dollars,
although you may continue to use any unclaimed dollars previously earned to reimburse eligible medical
expenses. Contact the Portico Customer Care Center for more information.

Page 8
Prescription Drug Benefit
When you have ELCA Medicare-Primary health benefits, your prescription drug benefit will differ
depending on whether you are retired or sponsored. This section includes provisions common to all
ELCA Medicare-Primary prescription drug benefits — the ELCA Part D drug benefit (for retired
members) and the ELCA prescription drug benefit (for sponsored, on leave from call, and non-U.S.
members) — and their eligible family members. Express Scripts, Inc. is your prescription drug benefit
administrator.
If you are retired, see the information starting on page 12 for specifics about the ELCA Part D
drug benefit.
If you are sponsored, on leave from call, or live outside the United States, see page 15 for
specifics about the ELCA prescription drug benefit.
With the ELCA Part D drug benefit and the ELCA prescription drug benefit, you have coverage for
most FDA-approved prescription drugs purchased for the treatment or prevention of illness and
conditions. ELCA prescription benefits don’t affect coverage under Medicare Part A or Part B or your
ELCA Medicare supplement benefit. If you’re eligible for Medicare Part A and Part B, you will
continue to receive those benefits from Medicare whether you have ELCA prescription drug coverage or
non-ELCA prescription drug coverage.
You pay a copayment for each drug purchase, and then the ELCA Health Plan pays 100% after the
copayment. You pay the lowest copayment for generic drugs, mid-level for preferred brand drugs (on
formulary), and highest for non-formulary drugs.
Eligible Prescription Drugs
Eligible prescription drugs include medically necessary:
Injectable and oral drugs determined to be specialty drugs by Express Scripts (when purchased
through Accredo Specialty Pharmacy for members with the ELCA prescription drug benefit)
Disposable diabetes supplies (not eligible under ELCA Part D drug benefit)
Certain drugs requiring preventive drug coverage by the Patient Protection and Affordable Care
Act
Drugs must be medically necessary for the condition, diagnosis, or symptoms, based on:
FDA-specific indications
Outcome data from clinical trials
National care and treatment standards
Express Scripts’ determination of appropriate use through the formulary and such programs as
prior authorization, drug quantity management, and step therapy
Preventive Medications
Under the Patient Protection and Affordable Care Act of 2010, you pay nothing when you meet the age
and condition requirements and purchase certain prescription drugs from an in-network retail pharmacy
or through Express Scripts home delivery, including:
Folic acid for women ages 18 – 50

Page 9
Smoking cessation drugs age 18 and older
Vitamin D supplements age 65 and older at increased risk for falls
Bowel preparation for colonoscopy screening ages 50 – 75 years
Breast cancer preventive drugs for women age 35 or older
Generic and certain brand name oral contraceptives
Oral fluoride for children ages six months through five years
Iron supplements for children ages six – 12 months
Immunizations
Aspirin for men ages 45 – 79 years and women ages 55 – 79 years at risk for cardiovascular
disease
Contact Express Scripts for specific drug information.
Medications Not Covered
Over-the-counter medications, except insulin and certain drugs requiring preventive coverage by
the Affordable Care Act when prescribed by a physician
Drugs for cosmetic treatment of hair loss or other cosmetic purposes
Vitamins for preventive purposes, except those required under the Affordable Care Act
Drugs taken in preparation for, or in conjunction with, artificial insemination
Drugs taken to terminate a pregnancy
Drugs considered not medically necessary, based on FDA-specific indications, clinical trial
outcomes, and national care and treatment standards
Drugs deemed by the benefit administrator as investigational or experimental because FDA
approval for marketing hasn’t been granted
Herbal, mineral, and nutritional supplements
Drugs that are covered under any other plan including those covered under a non-ELCA
Medicare prescription drug plan
Specialty drugs not purchased from Accredo (except members with the ELCA Part D drug
benefit)
Drugs covered as medical expenses under Medicare Part B for members with the ELCA Part D
drug benefit
Drugs excluded from the formulary
Most compounded medications due to lack of FDA approved uses

Page 10
Formulary
A formulary is a list of preferred medications reviewed and approved by a group of doctors and
pharmacists based on clinical effectiveness and cost. Formulary drugs include generic and preferred
brand-name medications that provide an affordable alternative to non-formulary drugs. If a generic
version of a drug becomes available midyear, the brand-name drug will become non-formulary from that
time forward.
Generic drugs — Typically are the lowest cost drugs for the plan and have the lowest of the
ELCA copayments. The FDA requires generics to have the same quality, strength, purity, and
stability as their brand-name equivalents.
Preferred drugs — Are brand-name drugs that have the mid-level costs for the plan and have
mid-level ELCA copayments. Preferred drugs are reviewed and approved for formulary
inclusion by an independent committee of doctors and pharmacists.
Non-formulary drugs — Are brand-name drugs that are the most expensive for the plan and
have the highest ELCA copayments. These drugs aren’t included on the formulary because they
are new to the marketplace or therapeutically equivalent to drugs available for less money.
Excluded drugs — Are drugs not covered by the plan. You pay the full price of any excluded
drug. Safe and clinically effective alternative drugs are covered by the plan.
The current formulary is available on myPortico and is subject to change without notice.
Short-Term Prescriptions
Prescriptions for up to a 31-day supply may be purchased at a local in-network pharmacy using your
Express Scripts identification card. You pay one of three copayments based on the type of drug: generic,
preferred brand-name, and non-formulary.
At the time of purchase, show your Express Scripts identification card, and the pharmacist will process
your prescription claim. There are no claims for you to file. If you use an out-of-network pharmacy or a
pharmacy outside the United States, you pay the full price at the time of purchase and submit a claim to
Express Scripts for reimbursement. For each up-to-31-day supply, you are responsible for your
copayment plus the difference between the purchase price and the Express Scripts contracted rate for
your prescription.
Network Pharmacies
Network pharmacies that participate in the Express Scripts network can be found using the Pharmacy
Locator at express-scripts.com or by calling Express Scripts. If you forget to show your identification
card at a participating pharmacy, you may be charged the full price for your prescription drug. Contact
the Portico Health Care Advocacy Team for assistance.
Out-of-Network Pharmacies
If you use an out-of-network pharmacy or a pharmacy outside the United States, you pay the full price at
the time of purchase and submit a claim to Express Scripts for reimbursement. For each up-to-31-day
supply, you’re responsible for your copayment plus the difference between the purchase price and the
Express Scripts contracted rate for your prescription.

Page 11
Maintenance Medications
Home Delivery Service
When you order a 90-day supply through Express Scripts home delivery service, you’ll pay less than
you would if you filled a 31-day supply three times at your local retail pharmacy. Standard shipping is
free. Express Scripts ships the order to your home or another address you designate. Most maintenance
medications ordered through Express Scripts home delivery are shipped by first-class mail. Perishable
drugs are shipped in temperature-controlled containers or cold packs via an overnight delivery service. If
you won’t be home to receive the package, you may request to have your order delivered to another
location, such as your office. This also helps protect perishable medications, such as insulin. To request
order forms for home delivery, contact Express Scripts.
Cost Saving and Safety Programs
Step Therapy
This program reduces the cost of drugs by requiring that specific high-cost, “step-two” drugs are
covered by the plan only after a clinically appropriate, proven, and more cost-effective “step-one” drug
is tried. If a step-one drug doesn’t provide the desired therapeutic benefit, the plan covers a step-two
drug. Step therapy drugs are subject to change without notice.
If you have certain medical conditions, you’ll need to ask your doctor to prescribe a step-one drug first.
For more information about step therapy, or if you have a question about a specific drug, contact
Express Scripts customer service or visit express-scripts.com.
Drug Quantity Management
A per-prescription quantity limit for certain medications promotes patient safety and avoids waste.
Quantity limits are based on FDA-approved prescription drug dosing guidelines. Quantity limits may
change midyear.
If your medication has a quantity limit, you make one copayment for each purchase of the maximum
allowed quantity. Even if your prescription is written for more than the allowed quantity, Express
Scripts fills only the maximum allowed quantity unless you obtain a medical necessity exception.
To obtain a medical necessity exception to the quantity limit, your doctor must contact Express Scripts
and request authorization for an exception. Authorization is required before an exception can be made. If
you have questions about quantity limits for a specific drug, contact Express Scripts.
Prior Authorization
Certain prescription drugs require approval by Express Scripts before a doctor’s prescription can be
dispensed, because the drugs are costly or may be used inappropriately.
Your doctor should call Express Scripts to request a prior authorization before writing a prescription.
Standard medical necessity criteria are used to review all coverage requests. If you have a question
about a specific drug, contact Express Scripts customer service or visit express-scripts.com.

Page 12
Hospital Stays
Prescription drugs administered during an inpatient hospital stay are considered medical expenses.
Prescription drugs purchased at a hospital pharmacy for use at home are considered prescription drug
expenses. To save money on drugs you will use at home, verify that the hospital pharmacy is in the
Express Scripts network and show your Express Scripts identification card. If the hospital pharmacy
isn’t in the Express Scripts network, you can save money by filling your prescription at your local
participating pharmacy.
NOTE: Generally, prescription drugs you take at home as part of outpatient treatment (for example, after
an emergency room visit), aren’t covered as a medical expense by Medicare Part B. You pay out-of-
pocket for these drugs and submit a claim to Express Scripts for reimbursement. Call the Portico Health
Care Advocacy Team for assistance.
Creditable Coverage
If you’re enrolled in the ELCA Medicare-Primary Premium, Standard, or Economy health benefit
option or the ELCA-Primary Platinum+, Gold+, or Silver+ health benefit option — ELCA
prescription drug coverage is creditable coverage. “Creditable coverage” means your ELCA prescription
drug coverage is, on average, as good as or better than Medicare’s standard prescription drug coverage.
Because you have creditable coverage, you can keep your ELCA coverage and not pay a late enrollment
penalty if you decide to enroll in Medicare prescription drug coverage within 63 days of ending ELCA
coverage.
If you’re enrolled in the ELCA-Primary Bronze+ health benefit option when you are eligible for
Medicare coverage — Your prescription drug coverage is non-creditable. That means the ELCA
prescription drug benefit included in the ELCA-Primary Bronze+ option is, on average, expected to pay
less than Medicare’s standard prescription drug coverage. If you have non-creditable coverage for any
period after your initial Medicare enrollment period when you are first eligible for Medicare, you will be
subject to a late-enrollment penalty (such as higher premiums) if you enroll in Medicare Part D
prescription drug coverage in the future.
If You Have the ELCA Part D Drug Benefit
If you’ve retired from sponsored employment and live in the United States or its territories, you and any
family members eligible for ELCA Medicare-Primary health benefits receive the ELCA Part D drug
benefit.
IMPORTANT:
If you have limited income and you qualify for extra help from Medicare with prescription drug
expenses, your copayments are less than shown in the chart on the next page.
If you have high yearly income (modified adjustable gross income of more than $85,000 per
individual or $170,000 for married couples filing jointly), you are required to pay an extra
amount to Social Security.
Certain diabetes and cancer-related medications — including diabetes test strips and supplies,
certain immunosuppressants, oral cancer drugs, agents used with a nebulizer, and antiemetic
drugs — are covered by Medicare Part B and can’t be filled by Express Scripts. Show your

Page 13
Medicare card when you buy Part B drugs and supplies at a local participating Medicare
pharmacy.
In most cases, your prescriptions are covered only if they are filled by Express Scripts home
delivery or an in-network Express Scripts pharmacy. If you use a non-participating pharmacy or
don’t present your Express Scripts card to an in-network pharmacy at the time of purchase, in
addition to the copayment, you’re responsible for the difference between the Express Scripts
contracted rate and the purchase price of your prescription.
2016 ELCA Part D Drug Benefit Chart
Administered by Express Scripts
Generic Drug
Preferred
Brand-Name Drug
Non-Formulary
Drug
Express Scripts/Medicare
Network Retail Pharmacy
Up to 31-day supply
100% after $10
copayment
100% and no copayment
for certain preventive
drugs. See list on page 8.
100% after $47
copayment
100% after $74
copayment
Express Scripts
Home Delivery
Up to 90-day supply
100% after $20
copayment
100% and no copayment
for certain preventive
drugs. See list on page 8.
100% after $100
copayment
100% after $160
copayment
Retail Maintenance Drug
Program Pharmacy
Up to 31-day supply
100% after $10
copayment
100% after $47
copayment
100% after $74
copayment
32- to 63-day supply
100% after $20
copayment
100% after $94
copayment
100% after $148
copayment
64- to 90-day supply
100% after $30
copayment
100% after $141
copayment
100% after $222
copayment
Accredo Specialty
Pharmacy
Up to 31-day supply
100% after $10
copayment
100% after $47
copayment
100% after $74
copayment
Non-Participating
Pharmacy
Up to 31-day supply
100% after $10
copayment plus
difference between
contracted rate and billed
amount
100% after $47
copayment plus
difference between
amount
100% after $74
copayment plus
difference between
amount

Page 14
Maintenance Medications
With the ELCA Part D drug benefit, you have two ways to order long-term prescriptions (90-day
supplies):
Home Delivery Service — Described on page 11.
Retail Maintenance Drug Program — You can fill up to a 90-day supply at a retail
maintenance drug program pharmacy that participates in Medicare’s network. Using this option
may cost more than Express Scripts home delivery. See the chart on the previous page for
copayment information.
Specialty Drugs
Specialty drugs are limited to a 31-day supply due to the high cost (average monthly cost is $1,500),
special storage needs, limited shelf life, and frequent dosage changes. Members with the ELCA Part D
drug benefit may purchase specialty drugs through the Express Scripts specialty pharmacy, Accredo.
Specialty drugs aren’t available through Express Scripts home delivery.
Medicare and ELCA Part D Drug Benefit
You cannot simultaneously have the ELCA Part D drug benefit and be covered under a non-ELCA
Medicare prescription drug plan. If you enroll in a non-ELCA Medicare prescription drug plan:
Your ELCA prescription drug benefit ends. Your Express Scripts card won’t work at retail
pharmacies, and you won’t be able to use Express Scripts home delivery service.
You’ll pay the monthly premium for non-ELCA Part D prescription drug coverage in addition to
the monthly contribution you already pay for your ELCA Medicare-Primary health benefits.
However, you won’t have the ELCA prescription drug benefit.
If you’re eligible for Medicare Part A and Part B, you continue to receive those benefits from
Medicare whether you have ELCA prescription drug coverage or non-ELCA prescription drug
coverage.
The ELCA Part D drug benefit is subject to Medicare’s rules and regulations for Medicare prescription
drug plans (Part D). Medicare determines which prescription drugs and quantities are eligible for the
ELCA Part D drug benefit. Certain additional drugs may be deemed eligible by the ELCA Health Plan.

Page 15
If You Have the ELCA Prescription Drug Benefit
If you’re eligible for Medicare and are sponsored, on leave from call, or living outside the United States,
you and any family members eligible for ELCA Medicare-Primary health benefits will receive the
ELCA prescription drug benefit. It’s the same prescription drug benefit received by plan members with
ELCA-Primary benefits. See page 8 for general information about your prescription drug benefit.
IMPORTANT:
Specialty drugs are limited to a 31-day supply and must be purchased from the Express Scripts
specialty pharmacy, Accredo.
Prescription drugs purchased at an in-network retail pharmacy are limited to a 31-day supply; if
purchased through Express Scripts home delivery, they’re limited to a 90-day supply.
If you use a non-participating pharmacy or don’t present your Express Scripts card to an in-
network pharmacy at the time of purchase, in addition to the copayment, you’re responsible for the
difference between the Express Scripts contracted rate and the purchase price of your prescription.
2016 ELCA Prescription Drug Benefit Chart
Administered by Express Scripts
Generic Drug
Preferred
Brand-Name Drug
Non-Formulary
Drug
Express Scripts/Medicare
Network Retail Pharmacy
Up to 31-day supply
100% after $10 copayment
100% and no copayment for certain
preventive drugs. See list on page 8.
100% after $47
copayment
100% after $74
copayment
Express Scripts
Home Delivery
Up to 90-day supply
100% and no copayment for certain
preventive drugs. See list on page 8.
100% after $100
copayment
100% after $160
copayment
Accredo Specialty
Pharmacy
Up to 31-day supply
100% after $47
copayment
100% after $74
copayment
Non-Participating
Pharmacy
Up to 31-day supply
100% after $10 copayment plus
difference between contracted rate
and billed amount
100% after $47
copayment plus
difference between
contracted rate and
billed amount
100% after $74
copayment plus
difference between
contracted rate and
billed amount
Specialty Drugs
Specialty drugs must be purchased through the Express Scripts specialty pharmacy, Accredo, to receive
coverage under the ELCA prescription drug benefit. Specialty drugs aren’t available at any time through
Express Scripts home delivery service or through your local retail pharmacy after the initial fill.
To purchase specialty drugs through an Accredo pharmacy, contact an Accredo patient care coordinator.
Syringes and needles for administering specialty drugs are provided to you by Accredo at no additional
cost. There is no shipping cost for specialty drugs.

Page 16
Dental Benefit
The dental benefit, administered by Delta Dental of Minnesota, covers preventive, basic, major
restorative, and orthodontic care. It covers allowed amounts for your eligible dental expenses subject to
the deductible, coinsurance, and maximum benefits payable amounts.
Reimbursement percentages are the same for any dentist, but you may have lower out-of-pocket
expenses if you use a dentist participating in a Delta Dental network. Network providers have agreed to
accept Delta Dental’s allowed amount as complete reimbursement for services, along with any
coinsurance or deductible for which you’re responsible.
IMPORTANT:
Out-of-network services are subject to the amount Delta Dental allows.
The dental benefit is not available if you opted out of dental coverage in 1996.
2016 Dental Benefit Chart
Administered by Delta Dental
Deductible and Benefit Limits You Pay
Annual Deductible
(member’s responsibility)
$150 per person
$300 per family
Annual Benefit Maximum (Other Than Orthodontia)
(maximum benefit paid per year by the plan for preventive, basic, and major
restorative care)
$2,850 per person
Lifetime Orthodontia Benefit Maximum
(maximum set in year services first received)
$2,850 per person
Type of Service Plan Pays
Diagnostic/Preventive Care
Teeth cleaning, twice per calendar year
Periodontal maintenance, twice per calendar year
Topical fluoride application, once per calendar year for age 18 or under
Oral examinations, twice per calendar year
Bite-wing X-rays, once every two calendar years for adults and one per
year for age 18 or under
Full mouth X-rays or Panorex, once every 60 months
Sealants for permanent molars, once per lifetime for age 18 or under
Space maintainers for extracted posterior primary teeth for age 18 or under
100%; no deductible
Basic Care
(fillings, tooth extractions, root canal therapy, oral surgery)
80% after deductible
Major Restorative Care
(crowns, bridges, dentures, implants)
50% after deductible
Orthodontia 50%; no deductible

Page 17
Eligible Dental Expenses
This benefit covers eligible dental expenses for procedures, services, or supplies received from a
qualified dentist or licensed dental care practitioner acting within the scope of her or his license or under
the supervision of a qualified dentist or doctor. The expenses must be for procedures, services, and
supplies that are:
Typically used for treatment of the dental condition
Rendered on the basis of generally accepted standards of dental practice
Medically necessary (except for specified preventive dental care)
Most dental procedures are performed and completed on the same day. However, some dental
procedures require multiple appointment dates. The claim is paid after the completion of all services
related to the procedure.
Pre-Treatment Estimate
If your dentist recommends dental care that is estimated to cost more than $300, have your dentist call
Delta Dental before you receive service to determine the allowed amount for the procedure.
Preventive Care
Your dental benefit pays 100% of eligible expenses for the following preventive dental care:
Routine dental cleaning — two per calendar year
Periodontal maintenance cleaning — two per calendar year
Oral exam — two per calendar year
Full-mouth X-ray or Panorex — one every 60 months
Bitewing X-rays — once every two calendar years for adults and once per year for dependents
through age 18
Topical application of fluoride — one per calendar year for dependents through age 18
Sealants or preventive resin restorations for permanent molars — one per lifetime for dependents
through age 18
Space maintainers for extracted posterior primary teeth for dependents through age 18
Oral hygiene instructions as prescribed by the dentist — one per lifetime per individual
Basic Dental Care
Your dental benefit pays 80% of eligible diagnostic, therapeutic, and restorative expenses (after
deductible) for the following basic dental care:
Oral exams, including specialist exams and those done in the course of emergency treatment for
the relief of pain
Tests and laboratory exams, including bacteriologic cultures and pulp vitality tests
Dental X-rays, including full-mouth or other dental X-rays required to diagnose and treat a
specific condition
Oral surgery:
Routine oral surgery for tooth removal (including alveolectomy, if indicated, and pre- and
post-operative care)

Page 18
All other oral surgeries, such as alveoloplasty, vestibuloplasty, removal of cysts, tumors,
growths, neoplasms, and treatment of simple fractures that can be managed in the office of a
qualified dentist or licensed dental care practitioner
Treatment of periodontal and other diseases of the gums and tissues of the mouth, including
gingivectomy, osseous surgery, and splinting. This includes periodontal scaling and root-planing,
repeat non-surgical treatment every 24 months, and repeat surgical treatment every 36 months.
Endodontic treatment, including root canal therapy and pulpotomies on primary and permanent
teeth (doesn’t cover retreatment of pulpotomies)
The following services and supplies, if provided in the office of a qualified dentist or licensed
dental care practitioner:
Anesthetics (conscious sedation), when medically necessary and administered in connection
with cutting procedures in the oral cavity
Injection of antibiotic drugs by an attending dentist
Application of desensitizing medications
Restoration of lost tooth structure as a result of tooth decay or fracture, when restored with
amalgams (silver alloys), resin (white-colored filling) restorations, or pre-formed crowns for
primary teeth
Removable appliances for the treatment of bruxism and other harmful habits
Major Restorative Care
Your dental benefit pays 50% of eligible expenses (after deductible) for the following services and
supplies related to major restorative dental care:
Repair or recementing of crowns, inlays, onlays, and fixed or removable dentures (including one
relining or rebasing of dentures every 36 consecutive months, if the relining or rebasing occurs
more than six months after the installation of an initial or replacement denture)
Crowns, onlays, or porcelain inlays when the amount of lost tooth structure cannot be restored
with filling restorations as described under Basic Dental Care above
Bridges, standard partial dentures, and full dentures for the replacement of extracted permanent
teeth. Eligible expenses are limited to the commonly performed method of tooth replacement.
Repairs and adjustments to prosthetic appliances if they serve as the permanent prosthetic
appliance
Replacement of an existing prosthetic appliance, if five years have elapsed from when last
benefited and only if the existing appliance is not and cannot be made satisfactory. Services that
are necessary to make an appliance satisfactory will be eligible.
Orthodontic Care
Your dental benefit covers orthodontic treatment for the prevention and correction of malocclusion of
teeth and associated dental and facial disharmonies. It pays 50% of eligible orthodontic expenses, up to a
lifetime benefit limit, including initial orthodontic examinations, X-rays, and models. The lifetime
benefit limit for each individual is fixed in the first year orthodontic expenses are incurred.

Page 19
Non-Eligible Expenses
Your dental benefit does not cover:
Charges that exceed allowed amounts
Procedures, services, or supplies primarily for cosmetic reasons and beautification, including
charges for personalization and characterization of dentures
Procedures, services, or supplies that aren’t necessary according to accepted standards of dental
practice. If a dentist or member elects an alternative or more expensive dental procedure, service,
or supply, the plan covers only the portion of the charge for the adequate treatment of the dental
condition.
Procedures, services, or supplies that don’t meet accepted standards of dental practice, including
those that are experimental
Replacement of a lost, missing, or stolen orthodontic or prosthetic device or any dental appliance
Precision attachments
Diagnosis or treatment of any disease, illness, injury, or physical condition that is covered under
medical or prescription drug benefits
Costs for dental veneers and related services and supplies
Costs for procedures, services, or supplies, including retreatment, that exceed the frequency
limits established by Delta Dental
Costs for procedures, services, or supplies that are medical in nature, including but not limited to
oral surgery services performed in a hospital
Inpatient and outpatient hospital expenses
Costs for prescription drug expenses
Out-of-Network Providers
If you receive care from an out-of-network provider, Delta Dental uses data for allowed amounts from
the Health Insurance Association of America. If your out-of-network dentist’s fee for a service is higher
than the fee charged by 80% of dentists in the same geographic area, the portion of the fee that exceeds
the allowed amount isn’t covered by this benefit. You’re responsible for paying any portion of the fee
that exceeds the allowed amount. The data is specific to each procedure performed by dentists and
grouped by geographic area.
Claims Payment
Ask your dentist to submit claims to the Delta Dental address on the back of your identification card. If
your dentist participates in Delta Dental networks, eligible dental expenses are paid directly to your in-
network provider. If your dentist doesn’t participate in Delta Dental’s networks, you’ll need to pay the
bill and Delta Dental sends payment to you rather than your out-of-network dentist.
Claim Filing Deadline
The claim filing deadline is 12 months from the date you incurred the expense. For example, if you incur
expenses on Feb. 12, 2016, you or the provider must file the claim before Feb. 12, 2017. Any claims
filed after the 12-month deadline will be denied.

Page 20
Health and Wellness Benefits
ELCA NurseLineSM
This service is provided by OptumSM
and is available to you 24 hours a day, seven days a week. Call the
ELCA NurseLineSM
at 877.856.8145 if you need help:
Deciding when self-care, a doctor visit, or the emergency room is appropriate
Knowing how to handle a common health problem
Understanding a medical condition, recent diagnosis, test results, or treatment options
Planning for your doctor visit
Understanding medication interactions and side effects
Portico provides plan members with a team of professionals who understand how the various parts of the
health care system fit together. Portico health care advocates know the ins and outs of our health plan
benefits including aspects like insurance billing and coding, Medicare payment rules and procedures,
insurance industry policies, and procedures. They work with you and our benefit administrators to
answer your questions and assist in resolving your problem. Contact the Portico Health Care Advocacy
Team (see Contact Information) for assistance.
Hearing Discount Program
Delta Dental of Minnesota partners with Amplifon to offer ELCA Health Plan members a hearing
discount program. Whether or not you have dental coverage, you and eligible family members can use
this program to save money. It offers:
Discounts on more than 1,000 models of digital hearing aids from leading manufacturers
A 40% discount on hearing diagnostic testing, including advanced audiology tests
A three-year warranty on most hearing aids, covering repairs, loss, and damage
A 60-day free trial with no restocking fee
Free batteries for two years with a new hearing aid purchase (maximum 160 cells per hearing aid)
One year of free aftercare services
More than 4,000 locations nationwide
Contact Amplifon (see Contact Information) for assistance.
Mayo Clinic Healthy Living
Portico contracts with Mayo Clinic Global Business Solutions to provide plan members access to Mayo
Clinic Healthy Living online. This website connects you with health and wellness information based on
the experience, knowledge, and credibility of more than 2,000 Mayo Clinic doctors and scientists.
Healthy Living also offers you an annual opportunity to complete the Mayo Clinic health assessment.
This online tool helps you take stock of your health and lifestyle habits in less than 30 minutes. You
enter personal health information (height, weight, cholesterol, blood sugar, etc.), and the tool identifies
your health strengths and risks. It also recommends strategies to maintain or improve health, and
delivers a personal action plan. Sign in to myPortico to access Mayo Clinic Healthy Living.

Page 21
SilverSneakers®
Fitness Program
This benefit gives you access to a basic fitness center membership at more than 13,000 participating
locations across the nation, at no cost to you. Whichever location you choose, you have access to the
equipment, group classes, and other services included in a basic fitness center membership. Use one
location or many to fit your needs. To start a basic membership, visit a participating fitness center and
present your SilverSneakers identification card.
The SilverSneakers Fitness Program also supports a healthy, active lifestyle outside the gym:
The FLEX™ program offers instructor-led classes like tai chi, yoga, and walking groups in
locations outside the gym, such as churches, community centers, and parks.
A SilverSneakers Steps®
kit helps you exercise at home or on the go. Contact SilverSneakers to
request a general fitness, strength, walking, or yoga kit.
The Healthways FIT website offers exercise demonstration videos, meal plans, healthy recipes,
inspirational stories, and discussion boards.
Contact SilverSneakers (see Contact Information) to learn more or find a participating fitness center.

Page 22
Contribution Rates
Contribution rates for ELCA Medicare-Primary health benefits reflect Medicare as primary payer for
hospital and medical expenses and are set annually by Portico.
If You’re Sponsored by an Eligible Employer
Your employer is responsible for paying the contribution amount for your coverage (for you and your
family). Rates are expressed as a percentage of your defined compensation (see Glossary).
If You’re Not Sponsored by an Employer
You’re responsible for paying all contributions associated with your participation in the health plan
(including coverage for your family). Your contribution is a flat rate per person per month.
NOTE: Former AELC clergy, ALC clergy and lay employees, and LCA clergy and certain churchwide
lay employees may have a portion of the cost of their coverage paid by the ELCA if they previously
participated in an AELC, ALC, or LCA health benefits plan and are eligible for a health subsidy.
If you’re retired and receiving a monthly participating annuity payment from the ELCA
Retirement Plan — You can deduct your health coverage contribution from your annuity payment (if
the annuity amount is greater than the cost of the health coverage). You are also eligible to waive health
benefits.
If you’re on leave from call — ELCA pastors and rostered laypersons on leave from call and wanting
to continue benefits must continue both health benefits (or waive health benefits, if eligible) and ELCA
basic group life insurance. To continue benefits, you pay the health contribution and the contribution for
basic group life insurance. If you’re a called interim pastor or interim rostered layperson serving under a
term call from a synod council and between assignments after completing an interim or term call from a
synod council, you can choose to purchase disability coverage for interims for up to 12 months at your
own expense.
If You’re Self Sponsored
You’re responsible for paying all contributions associated with your participation in the health plan
(including coverage for your family).

Page 23
2016 Monthly Contribution Rates
ELCA Medicare-Primary Benefits (Including Dental)
Economy Standard Premium
Members who are:
Retired
On leave from call
Spouses, ESGPs, surviving spouses
Continuing coverage after loss of
eligibility
$326 per person1,2
$652 per couple1,2
$340 per person1,2
$680 per couple1,2
$385 per person1,2
$770 per couple1,2
Children3
of members who are:
Retired
On leave from call
Divorced
Deceased
Continuing coverage after loss of
eligibility
$326 $340 $385
1.The ELCA may pay a portion for retired members and spouses who participated in a predecessor church plan. These rates
do not reflect any subsidies.
2.Less $49 for former retired LCA members who opted out of dental coverage in 1996.
3.If all children are eligible for Medicare coverage, this rate is for all children in a family.
NOTE: For ELCA-Primary health benefit contribution rates, visit myPortico or contact the Portico
Customer Care Center.
Late Contributions
If you’re responsible for paying the cost of your health coverage and don’t make the full payment within
60 days of the due date, your coverage under the ELCA Health Plan ends on the last day for which
contributions have been paid. If you’re a sponsored member and your employer can’t or won’t pay the
contribution, you may continue health coverage for up to 18 months at your own expense.
Medicare Part B Reimbursement
The ELCA Health Plan reimburses you for the cost of the Medicare Part B premium for you and your
spouse if you are enrolled in ELCA Medicare-Primary benefits and meet one of these criteria:
You or your spouse or ESGP are eligible for Medicare (age 65 or over) and you’re sponsored by
an organization with fewer than 20 employees
You’re disabled and receiving benefits from the ELCA Disability Benefits Trust
If you meet the criteria, to receive reimbursement, provide Portico proof of enrollment in Medicare Part
B within 60 days of your date of Part B eligibility. If proof is received after 60 days of eligibility, you’ll
be reimbursed the first of the month after Portico receives proof.

Page 24
Administrative and Miscellaneous Provisions
Confidentiality and Privacy Practices
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires health plans to
protect the confidentiality and privacy of individually identifiable health information. Portico is the plan
administrator of the ELCA Health Plan and is committed to maintaining the privacy of your personal
health information under the plan in accordance with HIPAA privacy standards. The plan and its benefit
administrators use and disclose health information only as allowed by federal law.
The plan has provided you with a Notice of Privacy Practices, describing how health information about
you may be used or disclosed by the plan. If you would like to receive another copy of this notice, please
contact the Portico Health Care Advocacy Team. (See Glossary for a brief list of your HIPAA rights and
page 33 for privacy contact information.)
Protected Health Information (PHI)
PHI is the identifiable health information about you that is created, received, or maintained by the ELCA
Health Plan. The privacy of your health information that is used or disclosed by the plan is protected by
HIPAA. The plan is required by law to:
Maintain the privacy of your PHI
Provide you with a notice of the plan’s legal duties and privacy practices with respect to your PHI
The ELCA Health Plan may use, share, or disclose PHI to pay your health benefits, operate the plan, or
for treatment by a health care provider. In addition, the plan may use or disclose your information in
other special circumstances described in the privacy notice. For any other purpose, the plan requires
your authorization for the use or disclosure of your PHI. An authorization form is available by calling
the Portico Health Care Advocacy Team (see Contact Information).
Third-Party Liability (Subrogation)
Subrogation is a legal process that allows Portico to substitute itself in your place regarding a claim or
legal right to compensation from a third party (person or entity) who was responsible for your injury or
illness.
Upon payment of benefits under the ELCA Health Plan, Portico will be subrogated to your rights of
recovery against any third party, including recoveries from:
People who commit wrongful acts, injuries, or damages for which a civil action can be brought
(tort-feasor)
Underinsured/uninsured motorist coverage
Employers’ and/or workers’ compensation insurers
Other substitute coverage or any other right of recovery, whether based on tort or contract
This applies to you and any person claiming benefits through you or on your behalf (trustee, personal
representative, executor, next of kin, heirs, etc.).

Page 25
Reimbursed first — Portico will be reimbursed from any recovery before payment of any other
existing claims, including any claim by you for general damages. The entire amount of any damages
recovered (not only the part specifically allocated to health care expenses) is considered reimbursement
for eligible expenses.
If you fail to remit to Portico any amount to which it is entitled, Portico may withhold the amount from
future payments under this plan.
Mandated insurance — If you fail to obtain any type of state or federal mandated insurance coverage
(Medicare, Medicaid, workers’ compensation, or no-fault insurance), Portico will be allowed to fully
assert our subrogation rights.
Lump-sum settlements — If you voluntarily accept a lump-sum (or other) settlement without the
consent of Portico and the settlement results in a waiver or abolishment of our subrogation rights against
the third party, we will be relieved of any obligation to pay past, present, or future claims or expenses
relating to the illness or injury.
Appeals Procedure
Initial steps — The health plan’s administrators are responsible for making decisions about claims or
requests for benefits according to the terms of the ELCA Health Plan. The initial determination of
benefits is made by the benefit administrator. If you are dissatisfied with the administrator’s initial
decision, you may pursue the administrator’s internal appeals procedures. If that process doesn’t satisfy
you, you can pursue next steps as follows:
Prescription drug benefit appeal — If the prescription drug benefit administrator denies your
initial benefit appeal, you can request an external independent review with an organization
contracted by the prescription benefit administrator to perform an independent review. The
decision of this review organization is final and binding.
Portico enrollment, eligibility, Medicare supplement, or dental benefit appeals
Presidential appeal — You may appeal in writing to the president of Portico within 180
days of your receipt of any adverse determination. Include the facts of your case, any new or
additional information not considered in the initial decision, and the outcome you desire.
Portico’s president reviews your claim with the advice and counsel of the internal appeals
committee, which consists of at least three staff members not involved with the initial
decision. The president will respond in writing within 30 days of receipt of your appeal and
signed authorization for disclosure of protected health information unless the president
notifies you of the need for an additional 30 days.
Portico’s president may approve an appeal only if it’s determined that an error was made in
the initial determination or the appeal involves matters relating to plan interpretation.
In the case of changing technology or circumstances, the president may recommend an
expansion of coverage requiring a plan amendment, which may or may not be retroactive. All

Page 26
plan amendments must be approved by the president, the board of trustees of Portico, and/or
the ELCA Church Council in accordance with the provisions described on page 28.
Appeals committee — An appeal may be filed with the appeals committee of Portico’s
board of trustees within 60 days of your receipt of the president’s written response if you are
dissatisfied with the decision of the president.
The appeals committee will consist of five to seven members of the board of trustees, at least
one of whom must be a participant in the ELCA Pension and Other Benefits Program.
Additionally, the committee may include independent consultants with expertise in the area
of the appeal, to serve with voice but not vote.
The appeals committee will schedule a meeting within 30 days of receiving your appeal and
signed authorization. The final decision of the appeals committee will be forwarded to you
within 60 days of receipt of the appeal. All decisions of the appeals committee are final.
Court system — In the event you have exhausted the previously described appeals
procedures and are dissatisfied with the final decision of the appeals committee of Portico,
you may initiate legal action in the Minnesota Fourth Judicial District Court, Hennepin
County. Any removal of such action must be to the United States Court for the District of
Minnesota. Legal action cannot be taken more than three years after the date of the event on
which the claim is based.
Limitation of Liability
Portico is not liable for the failure of any employer to enroll its rostered leader or lay employee as a
sponsored member in the ELCA Health Plan or for the failure of any employer to make contributions to
the plan on the member’s behalf. Also, Portico is not liable to any member or other person or entity for
any of its acts carried out in good faith and based upon information available at the time.
Obligations of a Sponsored Member
As a sponsored member of the ELCA Health Plan, you agree to comply with all of Portico’s
requirements regarding enrollment and administration of the plan. This includes, but is not limited to,
providing your:
Date of birth
Disability status
Marital status
Social Security number
Family support obligations
Medicare status
If you fraudulently or inappropriately use, misuse, or overuse these plan services and/or supplies,
Portico has the right to terminate your participation in the ELCA Pension and Other Benefits Program.
In addition, you won’t be eligible for coverage continuation under the ELCA Health Plan.

Page 27
Obligations of a Sponsoring Employer
By sponsoring an eligible employee in the ELCA Health Plan, the sponsoring employer agrees to:
Be bound by the terms of the ELCA Health Plan
Provide the necessary information to Portico for the administration of the ELCA Health Plan
Promptly notify Portico of any IRS audit or change in status that could cause the employer to
cease to be eligible to participate in the plan
An employer may discontinue participating in the ELCA Pension and Other Benefits Program by
notifying Portico and complying with any procedures established by Portico for discontinuing
participation. Portico may discontinue the participation of an employer if Portico, in its sole discretion,
determines the employer is no longer an eligible employer, as defined by the program, or if the employer
has failed to comply with the provisions of the program.
Correction of Errors
It is recognized that in the operation and administration of the ELCA Health Plan, certain mathematical
and accounting errors may be made or mistakes may arise for various reasons, including factual errors in
information supplied to the benefit administrators, Portico, or the board of trustees. Portico has the
power to make equitable adjustments to correct such errors as Portico, in its sole discretion, considers
appropriate. Adjustments will be final and binding on all persons.
Plan Information
While every effort has been made to ensure that the information contained in this communication is
correct, if there is any omission or misstatement, the applicable legal plan document will control. The
eligibility for any benefit will be governed by the terms of the applicable plan, program, or policy.
Portico (and its designee or the insurer or claims administrator, as applicable) shall have the power,
including, without limitation, discretionary power to make all determinations that the plan requires for
its administration, and to construe and interpret the plan for purposes of determining eligibility and
benefits. The assets of each plan are held in various trusts and therefore do not allow one plan to fund a
net shortfall of another plan.
Self-Insured Plan
The ELCA Health Plan is self-insured and is not provided through an insurance company. Portico’s
ability to pay claims is dependent on continued contributions, claims experience, and market
performance. Portico reserves the right to amend, modify, or terminate any plan or benefit policies or
programs, in whole or in part, at any time. Plan documents are available by contacting Portico. Our
policies, programs, and plans are not subject to the Employee Retirement Income Security Act (ERISA).
Although Portico has contracted with other companies to administer certain benefits of the plan, these
companies do not insure any part of the plan. All benefits to which a person becomes entitled hereunder
shall be provided only out of the ELCA Medical and Dental Benefits Trust and only to the extent that
such trust is adequate therefore.

Page 28
Amendment to the Plan
The ELCA Churchwide Assembly, the ELCA Church Council, or Portico may propose amendments to
the ELCA Health Plan. All proposed amendments must be submitted to Portico for recommendation
before final action is taken by the Church Council.
The president of Portico will approve amendments involving no change in policy and little or no
change in cost or benefits. Amendments approved by the president will be reported to the board
of trustees of Portico.
The Church Council will approve amendments involving a significant change in policy or a
significant change in cost or benefits. The Church Council may, in its sole discretion, submit any
proposed amendment to the Churchwide Assembly for final action.
The board of trustees of Portico will approve all other amendments. Amendments approved by
the board of trustees will be reported to the Church Council.
No amendment will reduce entitlement under the ELCA Health Plan for expenses incurred prior to the
effective date of the amendment.
No Guarantee of Tax Consequences
Portico makes no commitment or guarantee that any amounts paid to or for the benefit of a member
under the ELCA Health Plan will be excludable from the member’s gross income for federal, state, or
local income tax purposes. It is the member’s responsibility to determine whether each payment is
excludable from his or her gross income for income tax purposes. It is also the member’s responsibility
to notify Portico if he or she has any reason to believe a payment is not excludable for income tax
purposes.
Non-Assignability of Rights
The member’s rights to receive any reimbursement under the ELCA Health Plan are not transferable by
the member through assignment or any other method and are not subject to claims by the member’s
creditors by any process whatsoever. Any attempt to do so will not be recognized by Portico, except as
required by law.
Termination of the Plan
The ELCA Health Plan is designed, and contribution rates are established, to maintain long-term plan
viability. However, the ELCA Church Council may terminate the plan by following the previously
described amendment procedure. If the plan is terminated, the existing funds will be used to pay benefits
for expenses incurred prior to the effective date of the termination. Any surplus funds will be distributed
back to the ELCA. If the funds are distributed, no future benefit payments will be made from the plan.

Page 29
Glossary
Affordable Care Act
Signed into law March 23, 2010, the Patient
Protection and Affordable Care Act offers
comprehensive health reform. Some key health
coverage provisions of the law include an
expansion of Medicaid eligibility, the creation
of health insurance exchanges through which
eligible individuals are able to purchase
insurance with premium and cost-sharing
credits, regulations that prevent health insurers
from denying coverage to people, the
requirement that most individuals have health
insurance beginning in 2015, and penalties to
large employers that don’t offer affordable
coverage to their employees.
Brand-Name Drug
A drug that has a trade name and is typically
protected by a patent. It is known by this name
rather than its chemical name. Brand-name
drugs are usually sold for higher prices than
their generic equivalents.
Coinsurance
The percentage of eligible health care costs you
pay after meeting the deductible, up to the
annual out-of-pocket limit.
Copayment
A fixed dollar amount that ELCA Health Plan
members with certain health benefit options pay
for certain eligible health care services, such as
prescription drugs, usually when the services are
received.
Coverage Continuation
When eligible members pay the cost to keep
ELCA health benefits following a change in
employment. In some cases, coverage is
available for a limited period of time. Includes
members who are retired, on leave from call,
and separated from service, as well as surviving
spouses or eligible same gender partners, former
spouses, and other family members.
Coverage Continuation
Members
Individuals who were previously sponsored by
an employer in the ELCA benefit program but
now purchase ELCA benefits at their own
expense. Includes plan members who are
retired, on leave from call, and separated from
service, as well as surviving spouses or eligible
same gender partners, former spouses, and other
family members. Eligibility rules apply.
Deductible
The annual amount you pay for certain eligible
health care services before the health plan pays
anything.
Defined Compensation
Defined compensation includes base salary
before pretax benefit contributions are deducted.
If you’re a pastor, it includes Social Security tax
allowance paid to you and one of the following:
If housing isn’t provided, the amount of cash
housing allowance paid to you
If housing is provided, an additional 30% of
your base salary and Social Security tax
allowance, plus any household furnishings
or utilities allowance paid to you
Defined compensation doesn’t include:
Utilities paid directly by your congregation
or organization
Employer contributions including clergy
housing equity contributions made to the
ELCA Retirement Plan or another eligible
retirement plan
Non-taxable reimbursements or expense
allowances (auto and mileage, continuing
education, books, or professional expenses)

Page 30
Dental Benefit Administrator
Delta Dental, the entity contracted with Portico
to administer dental benefits. Responsibilities
include:
Credentials and contracts with dental
providers to provide treatment and services
to members who have dental coverage and
to accept negotiated rates as payment in full
Administers claims for eligible dental
expenses
Administers medical-necessity requirements
and allowed amount limits for dental
services
ELCA Medicare-Primary
Health Benefits
Health benefits available to ELCA Health Plan
members and their eligible family members who
are age 65 and over (unless sponsored by an
organization with 20 or more employees); in
addition to those under age 65 and receiving
Medicare due to a disability. Includes a choice
of three health benefit options: Premium,
Standard, and Economy; however, members
who are sponsored by an employer, on leave
from call, living outside the United States, or
receiving ELCA disability benefits are eligible
for the Standard option only.
Eligible Expense
A service or supply that is considered for
reimbursement under the ELCA Health Plan,
because it generally:
Is incurred while you or your family
member(s) are covered under the plan
Is billed to you (or your dependent)
Is ordered by an eligible plan provider
Is medically necessary
Is not specifically limited or excluded under
the rules of this plan
Meets the allowed amount guidelines used
by one of the plan’s benefit administrators
Eligible Same Gender Partner
(ESGP)
An individual who, together with a member of
the ELCA benefit program, properly completed
and signed an Affidavit of Partnership attesting
that they are not legally married but financially
interdependent (share financial obligations), not
married to or legally separated from anyone
else, and live in a publicly accountable, lifelong,
monogamous, same gender relationship.
Formulary
A list of both generic and preferred drugs
maintained by a prescription drug benefit
administrator. Formulary prescription drugs
generally cost ELCA Health Plan members, and
the plan, less than non-formulary drugs.
Generic Drug
A drug known by its chemical name rather than
by a brand name and not protected by patents.
The FDA requires generics to have the same
quality, strength, purity, and stability as brand-
name drugs. Generic drugs are usually sold for
significantly lower prices than their name-brand
equivalents.
Health Insurance Portability
and Accountability Act
(HIPAA) Rights
With respect to your protected health
information, under the Health Insurance
Portability and Accountability Act (HIPAA),
you have the right to:
Inspect and copy certain portions of your
PHI maintained by the plan
Request an amendment of your PHI
Request restriction on the uses and
disclosure of your PHI
Request communication be made to you
through an alternate means or location
Obtain an accounting of disclosures the plan
has made for reasons other than treatment,

Page 31
payment, health care operations, or for
required or authorized disclosures
Request that your provider not share PHI
with the plan if you paid for the entire service
Request copies of your health records in
electronic format, if available
Maintenance Medication
Medication taken on an ongoing basis for a
chronic condition.
Medigap Policy
A Medigap policy is private insurance that helps
you pay for some of the costs that Medicare
doesn’t cover, such as copayments, coinsurance,
and deductibles. Also called a Medicare
supplement policy. Medicare first pays its share
of Medicare-approved amounts, then a Medigap
policy pays its share. The ELCA Medicare-
Primary Economy health benefit option
provides similar benefits to the Medigap L
policy and the Premium option provides similar
benefits to the Medigap F policy.
Member
Any individual who is entitled to a benefit from
this plan including a sponsored member, spouse,
eligible same gender partner, alternate payee,
surviving spouse, surviving eligible same
gender partner, coannuitant, child of a
sponsored member, or a designated beneficiary.
Non-Formulary Drugs
Brand-name drugs that are not included on the
formulary because they are new to the
marketplace or there are therapeutically
equivalent drugs that cost less.
Preferred Brand-Name Drug
Preferred drugs are brand-name drugs that have
been reviewed and placed on the formulary by
an independent committee of doctors and
pharmacists.
Administrator
Express Scripts, Inc., the entity contracted with
Portico to administer the ELCA Part D drug
benefit and the ELCA prescription drug benefit.
Responsibilities include:
Contracts with participating network
pharmacies to provide prescription drugs to
members who have prescription drug
coverage and to accept negotiated rates as
payment in full
Operates the prescription drug home
delivery service
Establishes and administers medical-
necessity criteria
Administers claims for eligible prescription
drug expenses
Determines the list of eligible specialty
drugs and operates the specialty drug
pharmacy
Administers Medicare prescription drug
plans
Self-Insured Plan
A type of employer-provided benefit plan that
covers its own risk rather than insuring that risk
through a commercial insurance provider. The
ELCA health and disability plans and the retiree
survivor benefit are self-insured. While Portico
may contract with third-party administrators to
process claims, Portico pays the entire cost of
all our claims. Self-insured plans generally cost
less than fully-insured plans due to fewer fees
and the absence of sales commissions.
Separation from Service
When a member:
Who is not on the ELCA roster is no longer
serving in a participating congregation or
organization due to resignation, discharge,
retirement or death; or,
Who is on the ELCA roster is: (a) retired; or
(b) removed from the roster and is no longer
employed.

Page 32
NOTE: A member who is on the ELCA roster
and on leave from call is not considered
separated from service.
Supplement to Medicare
Benefit Administrator
Mercer Health & Benefits Administration LLC,
the entity contracted with Portico to administer
the ELCA Medicare supplement benefit and
responsible for administering supplement to
Medicare claims for eligible medical and
hospital expenses.

Page 33
Contact Information
Portico Benefit Services
myPortico.PorticoBenefits.org
Portico Customer Care Center
Call or email with questions about your
eligibility or contribution rates or if you have a
change of family status, address, or coverage.
800.352.2876 or 612.333.7651 / F 612.334.5399
mail@PorticoBenefits.org
Hours
7:30 a.m. – 6 p.m. (Central) Monday – Friday
Mailing address
800 Marquette Ave., Ste. 1050
Minneapolis, MN 55402-2892
Call or email if you need help understanding
your health benefits.
800.352.2876 or 612.333.7651 / F 612.752.4367
healthcare@PorticoBenefits.org
Hours
Privacy Contact
Call or email for information about the plan’s
privacy practice, to exercise your rights, or to
complain about how the plan is handling your
protected health information.
800.352.2876 or 612.333.7651, ext. 4420
privacycontact@PorticoBenefits.org
Attn: Privacy Contact
800 Marquette Ave., Ste. 1050
Medicare
medicare.gov
Contact Medicare with questions about Medicare
coverage, 24 hours a day, seven days a week.
800.MEDICARE [633.4227] / TTY
877.486.2048
Mercer Health & Benefits
Administration LLC
Medicare Supplement Benefit
Contact Mercer with questions about supplement
to Medicare hospital and medical benefits and
claims.
800.245.6728
Hours
Claims address
Mercer
P.O. Box 14426
Des Moines, IA 50306-3426
Amplifon
Hearing Discount Program
amplifonusa.com/deltadentalmn
Offered through a partnership with Delta Dental
of Minnesota, contact Amplifon to get discounts
on hearing aids and other hearing services.
855.531.4694
Hours
7 a.m. – 7 p.m. (Central) Monday – Friday
Delta Dental of Minnesota
Dental Benefit
deltadentalmn.org
Register or sign in to view claims history and to
locate a participating provider: choose Delta
Dental PPO or Delta Dental Premier providers.

Page 34
Customer service
Call about the benefit, claims, pretreatment
estimates, getting additional identification cards,
or to find a participating dentist.
800.448.3815 or 651.406.5901
Hours
Claims address
Delta Dental
P.O. Box 59238
Express Scripts, Inc.
express-scripts.com
Call or visit online to find participating
pharmacies in your area (select Pharmacy
Locator), order home delivery service
prescription refills, find opportunities to save
money, transfer a prescription to home delivery
service, and find information about drugs and
health conditions.
Hours
Accessible 24 hours a day, seven days a week
For Retired Members
877.866.6048 / TTY 800.899.2114
For Sponsored, On Leave from Call, and
Non-U.S. Members
800.575.8090 / TTY 800.899.2114
Prior Authorization (for Doctors Only)
Sometimes your doctor must request
authorization for certain drugs before the
prescription can be filled (for example, if the
quantity exceeds the limit or if a drug is
prescribed before the comparable, less expensive
step-one drug has been tried).
800.417.8164
Accredo Specialty Pharmacy
Contact Accredo (an Express Scripts subsidiary)
for assistance with specialty drugs, including
injectable and oral drugs with specific storage
and handling requirements.
800.803.2523
Hours
8 a.m. – 12 p.m. (Central) Saturday
Healthways
SilverSneakers®
Fitness Program
silversneakers.com
Contact Healthways SilverSneakers with
questions about your basic fitness membership at
participating fitness centers.
888.423.4632
Hours
Mayo Clinic Global Business
Solutions
Healthy Living Online Web Portal, Health
Assessment
Sign in to myPortico to access the Healthy
Living online web portal, take the health
assessment, and use wellness resources.
OptumSM
ELCA NurseLineSM
Call a registered nurse with health questions or
concerns 24 hours a day, seven days a week.
877.856.8145 / TTY 800.855.2880; ask to be
connected to 877.856.8145
Outside the United States: 800.411.7998 and
press “2” to speak to a nurse
Hours
Accessible 24 hours a day, seven days a week

Page 35
Cards for Your Wallet
The ELCA Medicare supplement benefit is administered by
Mercer Health & Benefits Administration LLC (formerly
Marsh). Show this card and your Medicare card to your
hospital and medical care providers. Contact Mercer at
800.245.6728 if you need additional identification cards.
Details of this benefit begin on page 3.
The ELCA Part D drug benefit for retired members with
ELCA Medicare-Primary benefits or those receiving
ELCA disability benefits is a Medicare Part D drug benefit
administered by Express Scripts, Inc. Show this card when you
purchase prescriptions at your local pharmacy. Use the
information on this card when you purchase prescription drugs
through Express Scripts home delivery service. Contact
Express Scripts at 877.866.6048 or visit express-scripts.com if
you need additional identification cards. Details of this benefit
begin on page 12.
The ELCA prescription drug benefit for members
sponsored by an employer, those on leave from call, or
living outside the United States is administered by Express
Scripts, Inc. Show this card when you purchase prescriptions at
your local pharmacy. Use the information on this card when
you purchase prescription drugs through Express Scripts home
delivery service. Contact Express Scripts at 800.575.8090 or
visit express-scripts.com if you need additional identification
cards. Details of this benefit begin on page 15.
The ELCA dental benefit is administered by Delta Dental of
Minnesota. Show this card to your dental care provider.
Contact Delta Dental at 800.448.3815 if you need additional
identification cards. Details of this benefit begin on page 16.

Page 36
100-07 (4/2016)

100_07_2016_SPD_ELCA_Medicare-Primary_Health_FINAL

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