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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