Evergreen Security Trust - Plan Comparisons

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PLAN COMPARISONS

These summaries are provided for convenience only and are not a formal part of any contract. They are not summary plan descriptions or summaries of material modifications. They are informal summaries of contracts only and do not include all contract provisions. Any deviations between these summaries and the actual contracts will be governed by the actual contract provisions.

Medical Plan Comparison
Dental Plan Comparison
Life/AD&D Plan Comparison

Forms & Plan Summaries

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For further information please contact our general agent:
DiMartino Associates, Inc.
1301 5th Avenue, Suite 3701
Seattle, WA 98101
Phone:   206-623-2430
Fax:       206-812-7550
Email:     Evergreen Security Trust

MEDICAL PLAN COMPARISON - SUMMARY 2008

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Benefit

PPO 250 (formerly Plan 1)

PPO 350 (formerly Plan 2)

PPO 500 (formerly Plan 3a)

FF750 (formerly Plan 3)

FF 1000 (new plan)

Selections (formerly plan 6)

PPO 50/50 (formerly Plan 4

HSA 1500 (formely Plan 5)

PPO Ded (new plan)

PPO 50/50 Decl Waived on RX (new plan)

PPO 90/60/20

PPO 80/50/25

PPO 80/50/30

PPO 80/50

POS 80/50/30

PPO 50/50/0

PPO HSA 80/60

PPO 50/50/0

Provider Network

Regence BlueShield Preferred Plan

Regence BlueShield Selections Network

Regence BlueShield Preferred Plan

Pref

Par

Pref

Par

Pref

Par

Pref

Par

Pref

Par

In-Net

Ex-Net

Pref

Par

Pref

Par

Pref

Par

Pref

Par

Lifetime Maximum

$2,000,000

Annual Deductible

$250/$500 waived on Office Call Visits

$350/$700 waived on Office Call Visits

$500/$1,000 waived on Office Call Visits

$750/$2,250 waived on First 4 Office Call Visits

$1,000/$3,000 waived on First 4 Office Call Visits

None

$500/
$1,000

No deductible

$1,000/$3,000

$500/$1,000

Annual Out-Of-Pocket Maximum

$2,000/$4,000

$2,000/$5,000

$3,500/$7,000

$2,500/$7,500

$5,000/$15,000

$3,500/
$7,000

$10,000/
$20,000

$3,500/$7,000

$5,000/$10,000

$2,500/$5,000

Coinsurance Level Professional & Facility/Services

90%

60%

80%

50%

80%

50%

80%

50%

80%

50%

80%

50%

80%

60%

50%

Office Call Copay

$20 then 100%

$20 then 60%

$25 then 100%

$25 then 50%

$30 then 100%

$30 then 50%

First 4 $25 then 100% then 80%

$25 then 50%

First 4 $25 then 100% then 80%

$25 then 50%

$30 then 80%

$30 then 50%

50%

80%

60%

50%

Emergency Room Copay

$125

$75

$125

80%

60%

$125

Preventive Care (unlimited)

$20 then 100%

$20 then 60%

$25 then 100%

$25 then 50%

$30 then 100%

$30 then 50%

$25 then 100%

$25 then 50%

$25 then 100%

$25 then 50%

$30 then 80%

Not covered

50%

80%

60%

50%

Mental/Nervous

Impatient

90% to 8 days

60% to 8 days

80% to 8 days

50% to 8 days

80% to 8 days

50% to 8 days

80% to 8 days

50% to 8 days

80% to 8 days

50% to 8 days

80% to 8 days

50% to 8 days

80% to 8 days

60% to 8 days

50% to 8 days

Outpatient

90% to 12 visits

60% to 12 visits

80% to 12 visits

50% to 12 visits

80% to 12 visits

50% to 12 visits

80% to 12 visits

50% to 12 visits

80% to 12 visits

50% to 12 visits

80% to 12 visits

50% to 12 visits

80% to 12 visits

60% to 12 visits

50% to 12 visits

Prescription Drug Benefit [1]

90%

80%

Rx $15/$40/$60

50%

80%

50%

50%
(not subject to deduct)

Vision (Not subject to any deductible requirements)

Exam paid at 100% subject to $20 copay

Exam paid at 100% subject to $25 copay

Exam paid at 100% subject to $30 copay

Exam paid at 100%

$30 then 80%

Not covered

Exam paid at 50%

Exam paid at 100%

Not covered

1 routine eye exam a year

Lenses & Frames every 2 years

Hardware 90% to $200

Hardware 80% to $200

Hardware 50% to $200

Hardware 80% to $200

Not covered

*Domestic Partner coverage available on all plans.

[1] Additional Plans (250a and 350a) are available with a $15/$40/$60 Rx copay program. Not Subject to Annual Deductible.

MEDICAL PLAN COMPARISON - SUMMARY 2007

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Benefits

PPO 250
(Plan 1)
PPO 90/60/20

PPO 350
(Plan 2)
PPO 80/50/20

PPO 500
(Plan 3A)
PPO 80/50/30

FF 750
(Plan 3)
PPO 80/50

FF 1000
New Plan
PPO 80/50

Selections
(Plan 6)
POS 80/50/30

PPO 50/50
(Plan 4)
PPO 50/50

Provider Network

Regence Blueshield
Preferred Plan

Regence Blueshield
Selections Network

Pref

Par

Pref

Par

Pref

Par

Pref

Par

Pref

Par

Pref

Par

In-Net

Ext-Net

Lifetime Maximum

$2,000,000

Annual Deductible

$200/$400 - waived on Office Call Visits

$300/$600 - waived on Office Call Visits

$750/$2250 - waived on First Four Office Call Visits

$500/$1000 - waived on Office Call Visits

No deductible

$1500/$3000

None

$500/$1000

Annual Out-of-Pocket Maximum

$1000/$2000

$1500/$3000

$2500/$75000

$2500/$5000

$5000/$10000

$2500/$5000

$10000/$20000

Coinsurance Level Professional & Facility Services

90%

60%

80%

50%

80%

50%

80%

50%

80%

60%

80%

50%

Office Call Copay

$20 then 100%

$20 then 60%

$20 then 100%

$20 then 50%

FirstFour $25 then 100% then 80%

$25 then 50%

$25 then 100%

$25 then 50%

50%

80%

60%

$25 then 80%

$25 then 50%

Emergency Room Copay

$75

Preventive care

$400 (deductible waived) subject to $20 copay

$400 (deductible waived) subject to $20

$300 (deductible waived) subject to $25 copay, not counted as first four

$400 (deductible waived) subject to $25 copay

50% to $400

$300 (deductible waived)

80% subject to $25 copay

No coverage except for mammograms

Mental & Nervous

Inpatient

90% to 12 days

80% to 12 days

80% to 8 days

80% to 12 days

50% to 12 days

80% to 8 days

80% to 12 days

50% to 6 days

Outpatient

90% to 15 visits

60% to 15 visits

80% to 15 visits

50% to 15 visits

80% to 15 visits

50% to 15 visits

80% to 15 visits

50% to 15 visits

80% to 12 visits

50% to 12 visits

80% to 15 visits

50% to 12 visits

Prescription Drug Benefit**

90%

80%

Rx $15/$30/$40

50%

80%

Rx $$15/$30/$40

Vision - one routine eye exam per year

Exam paid at 100% subject to $20 copay

Exam paid at 100% (deductible waived)

Exam paid at 100% subject to $25 copay

Exam paid at 50%

Exam paid at 100%

Exam paid at 80% subject to $25 copay

Lenses and frames - every 2 years

Hardware 90% to $200

Hardware 80% to $200

Hardware 50% to $200

Hardware 80% to $200

*Domestic partner coverage on all plans.
** Additional Plans (1a and 2a) are available with a $15/$30/$40 Rx copay program. Not Subject to Annual Dedectible.

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DENTAL PLAN COMPARISON - SUMMARY

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	Delta Premier / Preferred	Delta Premier / Preferred	Delta Premier	Delta Preferred
	Plan 1	Plan II	Plan III	Plan IV

Annual Deductible
Per Person -	$50	$25	$25	$25
(Waived on Class I benefits)
Family Maximum -	$150	$75	$75	$75
(Waived on Class I benefits)
Annual Maximum	$1,000	$2,000	$2,000	$1,500
(Per Calendar Year)	$1,000	$2,000	$2,000	$1,500
Class I - Diagnostic & Preventive	Benefit %	Benefit %	Benefit %	In Network	Out of Network
Exams	100%	100%	80%	100%	80%
Prophys
Fluoride
X-Rays
Sealants
Class II - Restorative	Benefit %	Benefit %	Benefit %	Benefit %	Benefit %
Restorations	80% / 90% if PPO	80% / 90% if PPO	80%	80%	70%
Endodontics
Periodontics
Oral Surgery
Class III - Major	Benefit %	Benefit %	Benefit %	Benefit %	Benefit %
Crowns	50%	50%	50%	50%	40%
Dentures
Partials
Bridges
Implants
Class IV - Orthodontia

This is a brief summary of benefits, it is not a certificate of coverage. For full coverage provisions, including a description of limitations and exclusions, please refer to the benefits booklet or contract. Dental coverage is underwritten by Washington Dental Service. Minimum group size is five.

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LIFE/AD&D PLAN COMPARISON - SUMMARY

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CONTRACT PROVISION

Basic Life Insurance/AD&D

Plan 1 is mandatory, the employer may choose Plan 2 or Plan 3:

Plan 1

$10,000

Plan 2

$25,000

Plan 3

$50,000

Age Reduction

Benefits reduce to:

At age:

60%

40%

30%

AD&D Schedule

100% for:

50% for:

Life

One hand

Both hands

One foot

Both feet

Sight of one eye

Sight of both eyes

Paraplegia

One hand and one foot

Hemiplegia

One hand and sight of one eye

Quadriplegia

One foot and sight of one eye

Seat Belt Benefit

Equal to AD&D benefit to $50,000 maximum

Accelerated Benefit

Available to eligible employees who are diagnosed with a terminal illness and have a life expectancy of less than 24 months. The insured may apply for up to 50% of the basic life insurance in force. The remaining % of benefit the employee does not elect is payable to the beneficiary upon the employee’s death.

Waiver of Premium
Total Disability Definition

Unable to work at any employment or occupation for which he/she is or becomes qualified by reason of education, training or experience and is not in fact engaged in any employment or occupation for wage or profit because of disability.

Waiver of Premium

Must be disabled prior to age 60. Waiver begins after employee has been totally disabled for 6 continuous months.

Waiver of Premium Termination

Provided employee remains disabled, does not terminate until the employee reaches age 70.

Basic Life Insurance Exclusions

None.

Basic AD&D Insurance Exclusions

Suicide or attempted suicide, riot, war or act of war, military service, felony, voluntary use of a controlled substance.

Coverage Termination

Basic Life Coverage continues 31 days past the date of employment termination (through the conversion privilege).

Eligibility

All employees enrolled in the Basic Life Plan. Coverage is provided for each eligible dependent of the insured, regardless of the number.

Dependent Life Benefits

$2,000 Spouse, $1,000 per Child.

Eligible Dependents

Legal spouse and children to age 23. Eligible children are natural children, foster children, step children or legally adopted children who depend upon the employee for support and either live with the employee or are a full-time student.

Exclusions

None.

Coverage Termination

Dependent Life coverage continues 31 days past the date of employee's employment termination (through the conversion privilege).

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