ROMAN CATHOLIC DIOCESE OF ALBANY |
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Total Monthly Premium Cost |
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Type | CDPHP HMO |
CDPHP CNY HMO |
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Individual | $822.84 | $923.50 | |||||
Two Person EE+Child | $1,645.67 | $1,847.00 | |||||
Two Person EE+Spouse | $1,645.67 | $1,847.00 | |||||
Family | $2,139.38 | $2,401.10 | |||||
Medicare | $822.84 | $923.50 | |||||
Total Annual Premium Cost |
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Type | CDPHP HMO |
CDPHP CNY HMO |
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Individual | $9,874.08 | $11,082.00 | |||||
Two Person EE+Child | $19,748.04 | $22,164.00 | |||||
Two Person EE+Spouse | $19,748.04 | $22,164.00 | |||||
Family | $25,672.56 | $28,813.20 | |||||
Medicare | $9,874.08 | $11,082.00 | |||||
Annual Cost to Your Employer |
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Type | CDPHP HMO |
CDPHP CNY HMO |
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Individual | $7,899.26 | $8,865.60 | |||||
Two Person EE+Child | $14,811.03 | $16,623.00 | |||||
Two Person EE+Spouse | $12,836.23 | $14,406.60 | |||||
Family | $19,254.42 | $21,609.90 | |||||
Medicare | $7,899.26 | $8,865.60 | |||||
Annual Cost to Employees |
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Type | CDPHP HMO |
CDPHP CNY HMO |
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Individual | $1,974.82 | $2,216.40 | |||||
Two Person EE+Child | $4,937.01 | $5,541.00 | |||||
Two Person EE+Spouse | $6,911.81 | $7,757.40 | |||||
Family | $6,418.14 | $7,203.30 | |||||
Medicare | $1,974.82 | $2,216.40 | |||||
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 |
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Inpatient Co-Pay | $500.00 | $500.00 | |||||
PCP/Specialist Co-Pay | $25/$40 | $25/$40 | |||||
Prescription Co-Pay | $10G/$40B/$70NF | $10G/$40B/$70NF | |||||
Out of Network | Covered for emergency or urgent care only | ||||||
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. The CDPHP Central New York (CNY) rates are for the Counties of Broome, Chenango, Delaware, Herkimer, Madison, Oneida, Otsego, and Tioga. |