Roman Catholic Diocese of Albany
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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 | $644.75 | $711.37 | $854.83 | ||||
| Two Person | $1,289.50 | $1,422.75 | $1,752.38 | ||||
| Family | $1,676.35 | $1,849.57 | $2,353.28 | ||||
| Medicare | $644.75 | $711.37 | $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 | $7,737.00 | $8,536.44 | $10,257.96 | ||||
| Two Person | $15,474.00 | $17,073.00 | $21,028.56 | ||||
| Family | $20,116.20 | $22,194.84 | $28,239.36 | ||||
| Medicare | $7,737.00 | $8,536.44 | $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 | $6,189.60 | $6,829.15 | $6,189.60 | ||||
| Two Person | $11,605.50 | $12,804.75 | $11,605.50 | ||||
| Family | $15,087.15 | $16,646.13 | $15,087.15 | ||||
| Medicare | $6,189.60 | $6,829.15 | $6,189.60 | ||||
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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 | $1,547.40 | $1,707.29 | $4,068.36 | ||||
| Two Person | $3,868.50 | $4,268.25 | $9,423.06 | ||||
| Family | $5,029.05 | $5,548.71 | $13,152.21 | ||||
| Medicare | $1,547.40 | $1,707.29 | $4,068.36 | ||||
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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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