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 Show More
