State of Connecticut

Attachment to MEMORANDUM NO. 2003-22

MSA TABLES - Semi-Monthly
Check Dates 6/30/2003 - 6/15/2004
Medical Prescription Drug
EMPLOYEE STATE STATE
NO. Amount NO. Amount NO. Amount
Chart A -Semi-Monthly (PAIRED D/OEs 7J/7H PRE-TAX) (SORT CODE 00001) SORT CODE 00076
D/OE 7W
Blue Cross State Preferred (PAIRED D/OEs 7G/7H POST-TAX) (SORT CODE 00001)
INDIVIDUAL 216 39.76 217 173.75 148 43.49
SUBSCRIBER + ONE 218 134.73 219 334.98 149 95.68
FAMILY 220 160.01 221 416.45 150 117.43
FLES 224 89.3 225 273.65 151 73.94
CHART B -Semi-Monthly (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 382 0 383 13.96
FAMILY 384 8.6 385 34.03
FLES 386 4.41 387 24.26
CHART C -Semi-Monthly (PAIRED D/OEs 5P/54 PRE-TAX) (SORT CODE 00159)
Blue Cross Dental w/A,B,&C (PAIRED D/OEs 42/54 POST-TAX) (SORT CODE 00159)
INDIVIDUAL 248 3.71 246 13.96
FAMILY 247 15.53 251 34.03
FLES 380 7.63 381 24.26
CHART D -Semi-Monthly (PAIRED D/OEs 6R/6P PRE-TAX) (SORT CODE 00079) SORT CODE 00076
D/OE 7W
BlueCare POE (PAIRED D/OEs 6N/6P POST-TAX) (SORT CODE 00079)
INDIVIDUAL 252 3.99 253 123.95 148 43.49
SUBSCRIBER + ONE 254 37.9 255 243.56 149 95.68
FAMILY 256 53.69 257 291.73 150 117.43
FLES 258 22.12 259 195.37 151 73.94
CHART E (PAIRED D/OEs 7U/7S PRE-TAX) (SORT CODE 00077) SORT CODE 00076
D/OE 7W
BlueCare Point of Service -Semi-Monthly (PAIRED D/OEs 7R/7S POST-TAX) (SORT CODE 00077)
INDIVIDUAL 288 11.02 289 126.14 148 43.49
SUBSCRIBER + ONE 290 62.12 291 239.62 149 95.68
FAMILY 292 73.31 293 297 150 117.43
FLES 294 27.52 295 205.64 151 73.94
CHART F (PAIRED D/OEs 6L/6J PRE-TAX) (SORT CODE 00006) SORT CODE 00076
D/OE 7W
ConnectiCare HMO Personal Care -Semi-Monthly (PAIRED D/OEs 6I/6J POST-TAX) (SORT CODE 00006)
INDIVIDUAL 771 0.36 772 109.00 332 27.62
SUBSCRIBER + ONE 773 25.23 774 215.35 333 60.77
FAMILY 775 34.69 776 260.57 334 74.58
FLES 777 14.28 778 171.62 335 46.96
CHART G (PAIRED D/OEs 6W/6U PRE-TAX) (SORT CODE 00259) SORT CODE 00076
D/OE 7W
Health Net Charter HMO -Semi-Monthly (PAIRED D/OEs 6T/6U POST-TAX) (SORT CODE 00259)
INDIVIDUAL 260 3.67 261 125.53 336 36.92
SUBSCRIBER + ONE 262 36.73 263 247.51 337 81.23
FAMILY 264 52.03 265 296.81 338 99.69
FLES 272 21.44 273 198.2 339 62.77
CHART H (PAIRED D/OEs 5R/5K PRE-TAX) (SORT CODE 00185)
CIGNA Dental Health -Semi-Monthly (PAIRED D/OEs 5J/5K POST-TAX) (SORT CODE 00185)
INDIVIDUAL 276 0.00 277 9.24
SUBSCRIBER + ONE 278 3.33 279 17.00
FAMILY 280 4.71 281 20.24
FLES 282 1.94 283 13.77
CHART I (PAIRED D/OEs 7P/7M PRE-TAX) (SORT CODE 00001) SORT CODE 00076
D/OE 7W
Blue Cross Out of Area Plan -Semi-Monthly (PAIRED D/OEs 7L/7M POST-TAX) (SORT CODE 00001)
INDIVIDUAL 344 11.02 345 196.19 148 43.49
SUBSCRIBER + ONE 340 62.12 341 393.73 149 95.68
FAMILY 346 73.31 347 486.14 150 117.43
FLES 348 27.52 349 324.72 151 73.94
CHART J (PAIRED D/OEs 5A/5C PRE-TAX) (SORT CODE 00078) SORT CODE 00076
BlueCare POE Plus -Semi-Monthly (PAIRED D/OEs 5B/5C POST-TAX) (SORT CODE 00078) D/OE 7W
INDIVIDUAL 284 1.49 285 118.73 148 43.49
SUBSCRIBER + ONE 286 30.15 287 234.33 149 95.68
FAMILY 296 41.46 297 283.12 150 117.43
FLES 298 17.06 299 187.30 151 73.94
CHART K (PAIRED D/OEs 5F/5L PRE-TAX) (SORT CODE 00261) SORT CODE 00076
D/OE 7W
Health Net CHARTER POS -Semi-Monthly (PAIRED D/OEs 5G/5L POST-TAX) (SORT CODE 00261)
INDIVIDUAL 354 10.43 355 123.54 336 36.92
SUBSCRIBER + ONE 356 58.76 357 235.96 337 81.23
FAMILY 358 69.35 359 292.35 338 99.69
FLES 360 26.03 361 201.71 339 62.77
CHART L (PAIRED D/OEs 5Q/5T PRE-TAX) (SORT CODE 00260) SORT CODE 00076
D/OE 7W
Health Net PASSPORT HMO -Semi-Monthly (PAIRED D/OEs 5S/5T POST-TAX) (SORT CODE 00260)
INDIVIDUAL 405 1.17 406 124.70 336 36.92
SUBSCRIBER + ONE 407 29.98 408 246.92 337 81.23
FAMILY 409 41.23 410 298.60 338 99.69
FLES 411 16.97 412 197.00 339 62.77
CHART M (PAIRED D/OEs 8N/8L PRE-TAX) (SORT CODE 00052) SORT CODE 00076
D/OE 7W
CTCARE POS OPEN ACCESS -Semi-Monthly (PAIRED D/OEs 8K/8L POST-TAX) (SORT CODE 00052)
INDIVIDUAL 448 9.99 449 126.06 332 27.62
SUBSCRIBER + ONE 472 56.28 473 243.02 333 60.77
FAMILY 474 66.42 475 300.90 334 74.58
FLES 476 24.93 477 206.34 335 46.96
CHART N (PAIRED D/OEs 8T/8R PRE-TAX) (SORT CODE 00054) SORT CODE 00076
D/OE 7W
CTCARE HMO OPEN ACCESS -Semi-Monthly (PAIRED D/OEs 8Q/8R POST-TAX) (SORT CODE 00054)
INDIVIDUAL 541 2.86 542 122.21 332 27.62
SUBSCRIBER + ONE 543 33.76 544 241.38 333 60.77
FAMILY 545 47.82 547 289.85 334 74.58
FLES 548 19.70 549 192.91 335 46.96

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