State of Connecticut

ATTACHMENT TO MEMORANDUM 2002-19

MSA TABLES 100% EMPLOYEE SHARE
Bi-Weekly Rates
SORT CODE TABLE NO EMPLOYEE
DEDUCTION
CHART AA Blue Cross Preferred POS 00001 D/OEs = PRE-TAX 7K, POST-TAX 7I
INDIVIDUAL 561 206.95
SUB+1 581 455.29
FAMILY 562 558.76
CHART BB BlueCare Point of Enrollment 00079 D/OEs = PRE-TAX 6S, POST-TAX 6Q
INDIVIDUAL 590 138.04
SUB+1 591 303.69
FAMILY 592 372.71
CHART CC BlueCare Point of Service 00077 D/OEs = PRE-TAX 7V, POST-TAX 7T
INDIVIDUAL 572 145.47
SUB+1 573 320.03
FAMILY 574 392.76
CHART DD ConnectiCare HMO Personal Care 00006 D/OEs = PRE-TAX 6M, POST-TAX 6K
INDIVIDUAL 569 113.56
SUB+1 570 249.84
FAMILY 571 306.62
CHART EE Health Net Charter HMO 00259 D/OEs = PRE-TAX 6X, POST-TAX 6V
INDIVIDUAL 593 139.53
SUB+1 594 306.96
FAMILY 595 376.73
CHART FF Blue Cross Dental A&C 00159 D/OEs = PRE-TAX 5X, POST-TAX 49
INDIVIDUAL 598 11.76
FAMILY 599 35.92
CHART GG CIGNA Dental 00185 D/OEs = PRE-TAX 5Y, POST-TAX 52
INDIVIDUAL 734 7.66
SUB+1 735 16.85
FAMILY 736 20.67
CHART HH Blue Cross Out of Area 00001 D/OEs = PRE-TAX 7Q, POST-TAX 7N
INDIVIDUAL 249 201.88
SUB+1 582 444.13
FAMILY 250 545.07
CHART II BlueCare POE Plus 00078 D/OEs = PRE-TAX 5D, POST-TAX 5E
INDIVIDUAL 300 131.82
SUB+1 301 290.01
FAMILY 302 355.92
CHART JJ Health Net Charter POS 00261 D/OEs = PRE-TAX 5M, POST-TAX 5N
INDIVIDUAL 362 143.53
SUB+1 363 315.77
FAMILY 364 387.53
CHART KK Health Net Passport HMO 00260 D/OEs = PRE-TAX 5U, POST-TAX 5V
INDIVIDUAL 413 136.73
SUB+1 414 300.80
FAMILY 415 369.16
CHART LL CTCARE POS Open Access 00052 D/OEs = PRE-TAX 8P, POST-TAX 8M
INDIVIDUAL 478 135.69
SUB+1 479 298.51
FAMILY 480 366.36
CHART MM CTCARE HMO Open Access 00054 D/OEs = PRE-TAX 8U, POST-TAX 8S
INDIVIDUAL 481 126.59
SUB+1 482 278.49
FAMILY 483 341.78

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