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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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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