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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