Annual Cost Chart

ROMAN CATHOLIC DIOCESE OF ALBANY
LAY EMPLOYEES PLAN FOR YEAR 2022

Total Monthly Premium Cost

Type CDPHP
HMO
CDPHP CNY
HMO
Individual $822.84 $923.50
Two Person EE+Child $1,645.67 $1,847.00
Two Person EE+Spouse $1,645.67 $1,847.00
Family $2,139.38 $2,401.10
Medicare $822.84 $923.50

Total Annual Premium Cost

Type CDPHP
HMO
CDPHP CNY
HMO
Individual $9,874.08 $11,082.00
Two Person EE+Child $19,748.04 $22,164.00
Two Person EE+Spouse $19,748.04 $22,164.00
Family $25,672.56 $28,813.20
Medicare $9,874.08 $11,082.00

Annual Cost to Your Employer

Type CDPHP
HMO
CDPHP CNY
HMO
Individual $7,899.26 $8,865.60
Two Person EE+Child $14,811.03 $16,623.00
Two Person EE+Spouse $12,836.23 $14,406.60
Family $19,254.42 $21,609.90
Medicare $7,899.26 $8,865.60

Annual Cost to Employees

Type CDPHP
HMO
CDPHP CNY
HMO
Individual $1,974.82 $2,216.40
Two Person EE+Child $4,937.01 $5,541.00
Two Person EE+Spouse $6,911.81 $7,757.40
Family $6,418.14 $7,203.30
Medicare $1,974.82 $2,216.40

Coverage Summary

This is a summary only. It is not intended to be a complete description of benefits which are governed by the contract between the Diocese and the insurer.

In Network CDPHP
HMO
CDPHP CNY
HMO
Inpatient Co-Pay $500.00 $500.00
PCP/Specialist Co-Pay $25/$40 $25/$40
Prescription Co-Pay $10G/$40B/$70NF $10G/$40B/$70NF
Out of Network Covered for emergency or urgent care only

The prescription co-pays are keyed as follows: G = Generic, B = Brand, NF = Non Formulary. A formulary is a listing of approved drugs by therapuetic class.

The CDPHP Central New York (CNY) rates are for the Counties of Broome, Chenango, Delaware, Herkimer, Madison, Oneida, Otsego, and Tioga.