Annual Cost Chart

ROMAN CATHOLIC DIOCESE OF ALBANY LAY EMPLOYEES PLAN FOR YEAR 2022
Total Monthly Premium Cost
Type	CDPHP HMO	CDPHP CNY HMO
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
Type	CDPHP HMO	CDPHP CNY HMO
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
Type	CDPHP HMO	CDPHP CNY HMO
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
Type	CDPHP HMO	CDPHP CNY HMO
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
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
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.