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.