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ROMAN CATHOLIC DIOCESE OF ALBANY HMO HEALTH PLAN OPTIONS |
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| Type | CDPHP HMO |
CDPHP CNY HMO |
Blue Shield HMO 206 |
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| Individual | $720.22 | $867.56 | $854.83 | ||||
| Two Person | $1,440.44 | $1,735.14 | $1,752.38 | ||||
| Family | $1,872.57 | $2,255.68 | $2,353.28 | ||||
| Medicare | $720.22 | $867.56 | $854.83 | ||||
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Total Annual Premium Cost |
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| Type | CDPHP HMO |
CDPHP CNY HMO |
Blue Shield HMO 206 |
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| Individual | $8,642.64 | $10,410.72 | $10,257.96 | ||||
| Two Person | $17,285.28 | $20,821.68 | $21,028.56 | ||||
| Family | $22,470.84 | $27,068.16 | $28,239.36 | ||||
| Medicare | $8,642.64 | $10,410.72 | $10,257.96 | ||||
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Annual Cost to Your Employer |
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| Type | CDPHP HMO |
CDPHP CNY HMO |
Blue Shield HMO 206 |
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| Individual | $6,914.11 | $8,328.58 | $6,914.11 | ||||
| Two Person | $12,963.96 | $15,616.26 | $12,963.96 | ||||
| Family | $16,853.13 | $20,301.12 | $16,853.13 | ||||
| Medicare | $6,914.11 | $8,328.58 | $6,914.11 | ||||
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Annual Cost to Employees |
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| Type | CDPHP HMO |
CDPHP CNY HMO |
Blue Shield HMO 206 |
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| Individual | $1,728.53 | $2,082.14 | $3,343.85 | ||||
| Two Person | $4,321.32 | $5,205.42 | $8,064.60 | ||||
| Family | $5,617.71 | $6,767.04 | $11,386.23 | ||||
| Medicare | $1,728.53 | $2,082.14 | $3,343.85 | ||||
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Coverage Summary |
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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. |
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| In Network | CDPHP HMO |
CDPHP CNY HMO |
Blue Shield HMO 206 |
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| Inpatient Co-Pay | $500.00 | $500.00 | $500.00 | ||||
| PCP/Specialist Co-Pay | $25/$40 | $25/$40 | $25 | ||||
| Prescription Co-Pay | $10G/$40B/$70NF | $10G/$40B/$70NF | $10G/$30B/$50NF | ||||
| Out of Network | |||||||
| Deductible | NA | NA | $500.00 | ||||
| Coinsurance | NA | NA | 30% | ||||
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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. 1. Blue Shield allows members to self refer to specialists in their network without a referral from their Primary Care Physician. 2. Blue Shield HMO 206 is a Plus option that offers out-of-network benefits, vision and limited dental benefits. Members select a Primary/Specialist co-pay. 3. The CDPHP Central New York (CNY) rates are for the Counties of Broome, Chenango, Delaware, Herkimer, Madison, Oneida, Otsego, and Tioga. |
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