State of Connecticut

Attachment to MEMORANDUM NO. 2003-19

MSA TABLES Bi-Weekly
July 2003 - June 2004
Medical Prescription Drug
EMPLOYEE STATE STATE
NO. Amount NO. Amount NO. Amount
Chart A Bi-Weekly (PAIRED D/OEs 7J/7H PRE-TAX) (SORT CODE 00001) SORT CODE 00076
Blue Cross State Preferred (PAIRED D/OEs 7G/7H POST-TAX) (SORT CODE 00001) D/OE 7W
INDIVIDUAL 010 36.7 011 160.38 109 40.14
SUBSCRIBER + ONE 012 124.37 013 309.21 110 88.32
FAMILY 014 147.7 015 384.42 111 108.39
FLES 018 82.43 019 252.61 112 68.25
CHART B Bi-Weekly (PAIRED D/OEs 5P/54 PRE-TAX) (SORT CODE 00159)
Blue Cross Dental w/A&C (PAIRED D/OEs 42/54 POST-TAX) (SORT CODE 00159)  
INDIVIDUAL 176 0 177 12.88
FAMILY 178 7.94 179 31.41
FLES 180 4.08 181 22.39
CHART D Bi-Weekly (PAIRED D/OEs 6R/6P PRE-TAX) (SORT CODE 00079) SORT CODE 00076
BlueCare POE (PAIRED D/OEs 6N/6P POST-TAX) (SORT CODE 00079) D/OE 7W
INDIVIDUAL 046 3.68 047 114.41 109 40.14
SUBSCRIBER + ONE 048 34.98 049 224.82 110 88.32
FAMILY 050 49.56 051 269.29 111 108.39
FLES 052 20.42 053 180.34 112 68.25
CHART E Bi-Weekly (PAIRED D/OEs 7U/7S PRE-TAX) (SORT CODE 00077) SORT CODE 00076
BlueCare Point of Service (PAIRED D/OEs 7R/7S POST-TAX) (SORT CODE 00077) D/OE 7W
INDIVIDUAL 082 10.17 083 116.43 109 40.14
SUBSCRIBER + ONE 084 57.34 085 221.19 110 88.32
FAMILY 086 67.67 087 274.16 111 108.39
FLES 088 25.4 089 189.83 112 68.25
CHART F Bi-Weekly (PAIRED D/OEs 6L/6J PRE-TAX) (SORT CODE 00006) SORT CODE 00076
ConnectiCare HMO Personal Care (PAIRED D/OEs 6I/6J POST-TAX) (SORT CODE 00006) D/OE 7W
INDIVIDUAL 763 0.33 764 100.61 126 25.50
SUBSCRIBER + ONE 765 23.28 766 198.79 127 56.09
FAMILY 767 32.02 768 240.53 128 68.84
FLES 769 13.18 770 158.42 129 43.34
CHART G Bi-Weekly (PAIRED D/OEs 6W/6U PRE-TAX) (SORT CODE 00259) SORT CODE 00076
Health Net Charter HMO (PAIRED D/OEs 6T/6U POST-TAX) (SORT CODE 00259) D/OE 7W
INDIVIDUAL 116 3.38 117 115.88 130 34.08
SUBSCRIBER + ONE 118 33.9 119 228.48 131 74.98
FAMILY 120 48.03 121 273.98 132 92.02
FLES 122 19.79 123 182.95 133 57.94
CHART H Bi-Weekly (PAIRED D/OEs 5R/5K PRE-TAX) (SORT CODE 00185)  
CIGNA Dental Health (PAIRED D/OEs 5J/5K POST-TAX) (SORT CODE 00185)
INDIVIDUAL 140 0.00 141 8.53
SUBSCRIBER + ONE 142 3.07 143 15.70
FAMILY 144 4.35 145 18.68
FLES 146 1.79 147 12.71
CHART I Bi-Weekly (PAIRED D/OEs 7P/7M PRE-TAX) (SORT CODE 00001) SORT CODE 00076
Blue Cross Out of Area Plan (PAIRED D/OEs 7L/7M POST-TAX) (SORT CODE 00001) D/OE 7W
INDIVIDUAL 134 10.17 135 181.1 109 40.14
SUBSCRIBER + ONE 124 57.34 125 363.44 110 88.32
FAMILY 136 67.67 137 448.75 111 108.39
FLES 138 25.4 139 299.75 112 68.25
CHART J Bi-Weekly (PAIRED D/OEs 5A/5C PRE-TAX) (SORT CODE 00078) SORT CODE 00076
BlueCare POE Plus (PAIRED D/OEs 5B/5C POST-TAX) (SORT CODE 00078) D/OE 7W
INDIVIDUAL 266 1.37 267 109.60 109 40.14
SUBSCRIBER + ONE 268 27.83 269 216.30 110 88.32
FAMILY 270 38.27 271 261.34 111 108.39
FLES 274 15.75 275 172.89 112 68.25
CHART K (PAIRED D/OEs 5F/5L PRE-TAX) (SORT CODE 00261) SORT CODE 00076
Health Net CHARTER POS Bi-Weekly (PAIRED D/OEs 5G/5L POST-TAX) (SORT CODE 00261) D/OE 7W
INDIVIDUAL 327 9.62 328 114.04 130 34.08
SUBSCRIBER + ONE 329 54.24 330 217.81 131 74.98
FAMILY 350 64.01 351 269.87 132 92.02
FLES 352 24.03 353 186.19 133 57.94
CHART L Bi-Weekly (PAIRED D/OEs 5Q/5T PRE-TAX) (SORT CODE 00260) SORT CODE 00076
Health Net PASSPORT HMO Bi-Weekly (PAIRED D/OEs 5S/5T POST-TAX) (SORT CODE 00260) D/OE 7W
INDIVIDUAL 397 1.08 398 115.10 130 34.08
SUBSCRIBER + ONE 399 27.67 400 227.93 131 74.98
FAMILY 401 38.05 402 275.64 132 92.02
FLES 403 15.66 404 181.85 133 57.94
CHART M (PAIRED D/OEs 8N/8L PRE-TAX) (SORT CODE 00052) SORT CODE 00076
CTCARE POS OPEN ACCESS Bi-Weekly (PAIRED D/OEs 8K/8L POST-TAX) (SORT CODE 00052) D/OE 7W
INDIVIDUAL 440 9.22 441 116.36 126 25.50
SUBSCRIBER + ONE 442 51.95 443 224.33 127 56.09
FAMILY 444 61.31 445 277.75 128 68.84
FLES 446 23.01 447 190.47 129 43.34
CHART N (PAIRED D/OEs 8T/8R PRE-TAX) (SORT CODE 00054) SORT CODE 00076
CTCARE HMO OPEN ACCESS Bi-Weekly (PAIRED D/OEs 8Q/8R POST-TAX) (SORT CODE 00054) D/OE 7W
INDIVIDUAL 524 2.64 525 112.80 126 25.50
SUBSCRIBER + ONE 526 31.16 527 222.82 127 56.09
FAMILY 528 44.14 529 267.56 128 68.84
FLES 530 18.18 531 178.08 129 43.34

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