DELL PEROT SYSTEMS
SUMMARY OF BENEFITS
2010
MEDICAL INSURANCE

Eligibility: Date of hire. Dependents covered to age 23; full-time students to age 25.
|Medical Insurance |
|Great West / Cigna Healthcare |
|Standard Plan |
|(www.mygreatwest.com) |
|Description |Coverage |
| |In-Network |Out-of-Network |
|Deductible |$500 Single/$1500 Family |$2000 Single/$6000 Family |
|Physician Co-Pay (Primary) |$25 per visit / $45 Specialist |Deductible + 50% |
|Preventive Care |$25 per visit |Deductible + 50% |
|Emergency Room Care |Deductible + 30% |Same as In-Network |
|Inpatient Hospital Services |Deductible + 20% |$500 Confinement Copay + 50% |
|Prescription Drugs |$10 Generic/$25 Brand Formulary/ |$10 Generic/$25 Brand/ |
| |$50 Brand Non-Formulary |$50 + 50% Brand Non-Formulary |
|COST PER BI-WEEKLY PAYCHECK |
|Employee |$ 0.00 |
|Employee + Child |$ 194.52 |
|Employee + Spouse |$ 235.04 |
|Employee + Family (Spouse/Children) |$ 324.32 |

NO Requirement to Select a Primary Care Physician

NO Referrals Needed

Ability to access Open Access Plus In-Network benefits Nationwide

|Medical Insurance |
|Great West / Cigna Healthcare |
|Premium Plan |
|(www.mygreatwest.com) |
|Description |Coverage |
| |In-Network |Out-of-Network |
|Deductible |$500 Single / $1500 Family |$2000 Single / $6000 Family |
|Physician Co-Pay (Primary) |$25 per visit / $45 Specialist