State of Connecticut

Attachment to MEMORANDUM NO. 2003-21

MSA TABLES 100% EMPLOYEE SHARE
Bi-Weekly Rates - TO BE USED ONLY FOR MSA PAYROLL DEDUCTIONS
  Medical and Dental Prescription Drug
SORT Employee
CODE No. Amount Amount
CHART AA Blue Cross Preferred POS 00001 D/OEs= PRE-TAX 7K, POST-TAX 7I SORT CODE 00076
PRE-TAX 7Y, POST-TAX 7X
INDIVIDUAL 561 197.08 40.14
SUB+1 581 433.58 88.32
FAMILY 562 532.12 108.39
CHART BB BlueCare Point of Enrollment 00079 D/OEs= PRE-TAX 6S, POST-TAX 6Q SORT CODE 00076
PRE-TAX 7Y, POST-TAX 7X
INDIVIDUAL 590 118.09 40.14
SUB+1 591 259.80 88.32
FAMILY 592 318.85 108.39
CHART CC BlueCare Point of Service 00077 D/OEs= PRE-TAX 7V, POST-TAX 7T SORT CODE 00076
PRE-TAX 7Y, POST-TAX 7X
INDIVIDUAL 572 126.60 40.14
SUB+1 573 278.53 88.32
FAMILY 574 341.83 108.39
CHART DD ConnectiCare HMO Personal Care 00006 D/OEs= PRE-TAX 6M, POST-TAX 6K SORT CODE 00076
PRE-TAX 7Y, POST-TAX 7X
INDIVIDUAL 569 100.94 25.5
SUB+1 570 222.07 56.09
FAMILY 571 272.55 68.84
CHART EE Health Net Charter HMO 00259 D/OEs= PRE-TAX 6X, POST-TAX 6V SORT CODE 00076
PRE-TAX 7Y, POST-TAX 7X
INDIVIDUAL 593 119.26 34.08
SUB+1 594 262.38 74.98
FAMILY 595 322.01 92.02
CHART FF Blue Cross Dental A&C 00159 D/OEs= PRE-TAX 5X, POST-TAX 49  
INDIVIDUAL 598 12.88
FAMILY 599 39.35
CHART GG CIGNA Dental 00185 D/OEs= PRE-TAX 5Y, POST-TAX 52  
INDIVIDUAL 734 8.53
SUB+1 735 18.77
FAMILY 736 23.03
CHART HH Blue Cross Out of Area 00001 D/OEs= PRE-TAX 7Q, POST-TAX 7N SORT CODE 00076
PRE-TAX 7Y, POST-TAX 7X
INDIVIDUAL 249 191.27 40.14
SUB+1 582 420.78 88.32
FAMILY 250 516.42 108.39
CHART II BlueCare POE Plus 00078 D/OEs= PRE-TAX 5D, POST-TAX 5E SORT CODE 00076
PRE-TAX 7Y, POST-TAX 7X
INDIVIDUAL 300 110.97 40.14
SUB+1 301 244.13 88.32
FAMILY 302 299.61 108.39
CHART JJ Health Net Charter POS 00261 D/OEs= PRE-TAX 5M, POST-TAX 5N SORT CODE 00076
PRE-TAX 7Y, POST-TAX 7X
INDIVIDUAL 362 123.66 34.08
SUB+1 363 272.05 74.98
FAMILY 364 333.88 92.02
CHART KK HealthNet Passport HMO 00260 D/OEs= PRE-TAX 5U, POST-TAX 5V SORT CODE 00076
PRE-TAX 7Y, POST-TAX 7X
INDIVIDUAL 413 116.18 34.08
SUB+1 414 255.60 74.98
FAMILY 415 313.69 92.02
CHART LL CTCARE POS Open Access 00052 D/OEs= PRE-TAX 8P, POST-TAX 8M SORT CODE 00076
PRE-TAX 7Y, POST-TAX 7X
INDIVIDUAL 478 125.58 25.5
SUB+1 479 276.28 56.09
FAMILY 480 339.06 68.84
CHART MM CTCARE HMO Open Access 00054 D/OEs= PRE-TAX 8U, POST-TAX 8S SORT CODE 00076
PRE-TAX 7Y, POST-TAX 7X
INDIVIDUAL 481 115.44 25.5
SUB+1 482 253.98 56.09
FAMILY 483 311.70 68.84

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