Attachment to MEMORANDUM NO. 2004-16
| State Employee Health Insurance | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7/1/2004 TO 6/30/2005 Employee Share Rates Based on Final Premium Rates for Contributions | |||||||||||||||
| Bi-Weekly Rates Based on 26 Pay Periods | |||||||||||||||
| Medical Plans Including Rx Drug | Dental Plans | ||||||||||||||
| Anthem | Health Net | ConnectiCare | Blue Cross Indemnity | ||||||||||||
| Blue Cross | State BlueCare | ||||||||||||||
| State Preferred | Out of Area | POS | POE | POE Plus | Charter POS | Charter HMO | Passport HMO | POS Open Access | HMO Open Access | HMO Personal Care Plan | A & C | A, B & C | CIGNA | ||
| Individual | Monthly | $92.20 | $25.56 | $25.56 | $ 11.25 | $ 6.25 | $24.13 | $ 10.47 | $ 5.47 | $23.04 | $ 8.54 | $ 3.54 | $0.00 | $8.02 | $0.00 |
| Semi-Monthly | $46.10 | $12.78 | $12.78 | $5.63 | $3.13 | $12.07 | $5.24 | $2.74 | $11.52 | $4.27 | $1.77 | $0.00 | $4.01 | $0.00 | |
| Bi-Weekly | $42.55 | $11.80 | $11.80 | $5.19 | $2.88 | $11.14 | $4.83 | $2.52 | $10.63 | $3.94 | $1.63 | $0.00 | $3.70 | $0.00 | |
| Subscriber+1 | Monthly | $312.47 | $144.06 | $144.06 | $87.90 | $69.91 | $136.00 | $85.01 | $69.37 | $129.86 | $77.90 | $58.20 | $18.59 | $33.56 | $7.16 |
| Semi-Monthly | $156.24 | $72.03 | $72.03 | $43.95 | $34.96 | $68.00 | $42.51 | $34.69 | $64.93 | $38.95 | $29.10 | $9.29 | $16.78 | $3.58 | |
| Bi-Weekly | $144.22 | $66.49 | $66.49 | $40.57 | $32.27 | $62.77 | $39.24 | $32.02 | $59.94 | $35.95 | $26.86 | $8.58 | $15.49 | $3.30 | |
| Family | Monthly | $371.09 | $170.01 | $170.01 | $124.52 | $96.15 | $160.50 | $120.42 | $95.42 | $153.25 | $110.34 | $80.05 | $18.59 | $33.56 | $10.14 |
| Semi-Monthly | $185.55 | $85.01 | $85.01 | $62.26 | $48.08 | $80.25 | $60.21 | $47.71 | $76.63 | $55.17 | $40.03 | $9.29 | $16.78 | $5.07 | |
| Bi-Weekly | $171.27 | $78.47 | $78.47 | $57.47 | $44.38 | $74.08 | $55.58 | $44.04 | $70.73 | $50.93 | $36.95 | $8.58 | $15.49 | $4.68 | |
| FLES | Monthly | $207.10 | $63.81 | $63.81 | $51.30 | $39.56 | $60.24 | $49.61 | $39.26 | $57.52 | $45.46 | $32.94 | $9.54 | $16.49 | $4.17 |
| Semi-Monthly | $103.55 | $31.91 | $31.91 | $25.65 | $19.78 | $30.12 | $24.81 | $19.63 | $28.76 | $22.73 | $16.47 | $4.77 | $8.24 | $2.09 | |
| Bi-Weekly | $95.58 | $29.45 | $29.45 | $23.68 | $18.26 | $27.80 | $22.90 | $18.12 | $26.55 | $20.98 | $15.20 | $4.40 | $7.61 | $1.93 | |
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