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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 | $695.90 | $796.15 | $854.83 | ||||
| Two Person | $1,391.80 | $1,592.31 | $1,752.38 | ||||
| Family | $1,809.35 | $2,070.00 | $2,353.28 | ||||
| Medicare | $695.90 | $796.15 | $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 | $8,350.80 | $9,553.80 | $10,257.96 | ||||
| Two Person | $16,701.60 | $19,107.72 | $21,028.56 | ||||
| Family | $21,712.20 | $24,840.00 | $28,239.36 | ||||
| Medicare | $8,350.80 | $9,553.80 | $10,257.96 | ||||
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Annual Cost to Employers |
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| Type | CDPHP HMO |
CDPHP CNY HMO |
Blue Shield HMO 206 |
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| Individual | $6,680.64 | $7,643.04 | $6,680.64 | ||||
| Two Person | $12,526.20 | $14,330.79 | $12,526.20 | ||||
| Family | $16,284.15 | $18,630.00 | $16,284.15 | ||||
| Medicare | $6,680.64 | $7,643.04 | $6,680.64 | ||||
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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 | $1,670.16 | $1,910.76 | $3,577.32 | ||||
| Two Person | $4,175.40 | $4,776.93 | $8,502.36 | ||||
| Family | $5,428.05 | $6,210.00 | $11,955.21 | ||||
| Medicare | $1,670.16 | $1,910.76 | $3,577.32 | ||||
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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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