State of Connecticut

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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