Annual Cost Chart

ROMAN CATHOLIC DIOCESE OF ALBANY HMO HEALTH PLAN OPTIONS
EFFECTIVE JANUARY 1, 2018 WITH MONTHLY PREMIUM RATES

Type CDPHP
HMO
CDPHP CNY
HMO
Blue Shield
HMO 206
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

Total Annual Premium Cost

Type CDPHP
HMO
CDPHP CNY
HMO
Blue Shield
HMO 206
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

Annual Cost to Employers

Type CDPHP
HMO
CDPHP CNY
HMO
Blue Shield
HMO 206
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

Annual Cost to Employees

Type CDPHP
HMO
CDPHP CNY
HMO
Blue Shield
HMO 206
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

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
Blue Shield
HMO 206
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%

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.