ROMAN CATHOLIC DIOCESE OF ALBANY HMO HEALTH PLAN OPTIONS
EFFECTIVE JANUARY 1, 2018 WITH MONTHLY PREMIUM RATES

Type CDPHP
HMO
CDPHP CNY
HMO
Blue Shield
HMO 206
Individual $695.90 $796.15 $854.83
Two Person $1,391.80 $1,592.31 $1,752.38
Family $1,809.35 $2,070.00 $2,353.28
Medicare $695.90 $796.15 $854.83

Total Annual Premium Cost

Type CDPHP
HMO
CDPHP CNY
HMO
Blue Shield
HMO 206
Individual $8,350.80 $9,553.80 $10,257.96
Two Person $16,701.60 $19,107.72 $21,028.56
Family $21,712.20 $24,840.00 $28,239.36
Medicare $8,350.80 $9,553.80 $10,257.96

Annual Cost to Employers

Type CDPHP
HMO
CDPHP CNY
HMO
Blue Shield
HMO 206
Individual $6,680.64 $7,643.04 $6,680.64
Two Person $12,526.20 $14,330.79 $12,526.20
Family $16,284.15 $18,630.00 $16,284.15
Medicare $6,680.64 $7,643.04 $6,680.64

Annual Cost to Employees

Type CDPHP
HMO
CDPHP CNY
HMO
Blue Shield
HMO 206
Individual $1,670.16 $1,910.76 $3,577.32
Two Person $4,175.40 $4,776.93 $8,502.36
Family $5,428.05 $6,210.00 $11,955.21
Medicare $1,670.16 $1,910.76 $3,577.32

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.