ROMAN CATHOLIC DIOCESE OF ALBANY HMO HEALTH PLAN OPTIONS
EFFECTIVE JANUARY 1, 2017 WITH MONTHLY PREMIUM RATES

Type CDPHP
HMO
CDPHP CNY
HMO
Blue Shield
HMO 206
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

Total Annual Premium Cost

Type CDPHP
HMO
CDPHP CNY
HMO
Blue Shield
HMO 206
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

Annual Cost to Employers

Type CDPHP
HMO
CDPHP CNY
HMO
Blue Shield
HMO 206
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

Annual Cost to Employees

Type CDPHP
HMO
CDPHP CNY
HMO
Blue Shield
HMO 206
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

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.