Annual Cost Chart

ROMAN CATHOLIC DIOCESE LAY EMPLOYEES PLAN FOR YEAR 2021
Total Monthly Premium Cost
Type	CDPHP HMO	CDPHP CNY HMO	Blue Shield HMO 206
Individual	$794.69	$897.67	$880.17
Two Person EE+Child	$1,589.38	$1,795.33	$1,804.33
Two Person EE+Spouse	$1,589.38	$1,795.33	$1,804.33
Family	$2,066.19	$2,333.91	$2,423.09
Medicare	$794.69	$897.67	$880.17
Total Annual Premium Cost
Type	CDPHP HMO	CDPHP CNY HMO	Blue Shield HMO 206
Individual	$9,536.28	$10,772.04	$10,562.04
Two Person EE+Child	$19,072.56	$21,543.96	$21,651.96
Two Person EE+Spouse	$19,072.56	$21,543.96	$21,651.96
Family	$24,794.28	$28,006.92	$29,077.08
Medicare	$9,536.28	$10,772.04	$10,562.04
Annual Cost to Your Employer
Type	CDPHP HMO	CDPHP CNY HMO	Blue Shield HMO 206
Individual	$7,629.02	$8,617.63	$7,629.02
Two Person EE+Child	$14,304.42	$16,157.97	$14,304.42
Two Person EE+Spouse	$12,397.16	$14,003.57	$12,397.16
Family	$18,595.71	$21,005.19	$18,595.71
Medicare	$7,629.02	$8,617.63	$7,629.02
Annual Cost to Employees
Type	CDPHP HMO	CDPHP CNY HMO	Blue Shield HMO 206
Individual	$1,907.26	$2,154.41	$2,933.02
Two Person EE+Child	$4,768.14	$5,385.99	$7,347.54
Two Person EE+Spouse	$6,675.40	$7,540.39	$9,254.80
Family	$6,198.57	$7,001.73	$10,481.37
Medicare	$1,907.26	$2,154.41	$2,933.02
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	$25.00
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.