2015 Summary of Benefits
Updated January 2015
Provider Contact List
New Mexico Retiree Health Care Authority
Main Number 1-800-233-2576 or Santa Fe 505-476-7340
Medical
Blue Cross Blue Shield of New Mexico
(Non Medicare and Medicare Supplement)
1-800-788-1792
5701 Balloon Fiesta Parkway
Albuquerque, NM 87113 or
PO Box 27630
Albuquerque, NM 87125
www.bcbsnm.com
Presbyterian Health Plan (Non Medicare)
1-888-275-7737
ABQ: 505-923-6060
TTY: 1-888-625-8818
Albuquerque, NM 87125
7 days a week
8:00 am to 8:00 pm
www.phs.org
1-877-299-1008
5701 Balloon Fiesta Parkway
Presbyterian Medicare Advantage (Medicare) 1-800-797-5343
BCBS Medicare Advantage (Medicare)
PO Box 27486
Albuquerque, NM 87113 or
PO Box 27630
Albuquerque, NM 87125
www.bcbsnm.com
United Health Care (Medicare)
1-866-622-8014
www.uhcretiree.com
Prescription Drug (For all PPO Plans and
BCBS Supplemental
Medicare)
Express Scripts
Medicare:
www.express-scripts.com
1-800-551-1866
Non-Medicare:
1-800-501-0987
Dental
Delta Dental
1-877-395-9420
2500 Louisiana Blvd. NE Ste 600
ABQ: 505-855-7111
Albuquerque, NM 87110
www.deltadentalNM.com
Monday—Friday 8:00am to 4:30pm
United Concordia
1-888-898-0370 *0
Claims
PO Box 69421
Harrisburg, PA 17106
www.ucci.com
Vision
Davis Vision
1-800-999-5431
All prospective clients can use code 7587 when
requesting a provider list or previewing plans.
6301 Indian School Rd NE, Ste 200
Albuquerque, NM 87110
www.davisvision.com
Life Insurance
Standard Life Insurance
1-888-609-9763 opt 4
8201 Golf Course Rd NW, #D3 336
Martha Quintana, Account Manager
ABQ: 505-859-4180
Albuquerque, NM 87120
www.standart.com/mybenefits/
newmexico_rhca/
IMPORTANT INFORMATION YOU NEED TO KNOW
Note: This informational sheet is intended as a summary to, and not a replacement of,
provisions of the Retiree Health Care Act (Act) or NMRHCA Rules and Regulations
(which can be found on the NMRHCA website: www.nmrhca.state.nm.us)
ELIGIBILITY
Eligible Retiree: You are eligible to participate in the NMRHCA if:

You receive a disability or normal retirement benefit from public service in New
Mexico with an NMRHCA-participating employer, and
 You did one of the following:
 you retired with a pension before your employer’s effective date with the
NMRHCA program, or
 you and/or your employer (on your behalf) made contributions to the
NMRHCA fund from your employer’s NMRHCA effective date until your
date of retirement, or
 you and/or your employer (on your behalf) made contributions to the
NMRHCA fund for at least five years before your date of retirement.
(If you are awarded a duty-related disability retirement, you are not required to meet
the NMRHCA’s five-year contribution rule.)
Eligible Dependent: Eligible dependents include the following:
 a spouse. You must provide a copy of the marriage certificate.
 a domestic partner. You must provide a signed and notarized affidavit (available at
the NMRHCA office).
 domestic partners are enrolled similarly to spouses
 dependents of domestic partnerships are eligible for benefits
 we may ask for other written proof of the domestic partnership and/or
dependents
 if there is a termination of a domestic partnership, the retiree must notify
NMRHCA in writing within 31 days of the termination
 a dependent child under the age of 26 including:
 a natural child
 a legally adopted child
 a stepchild living in the same household who is primarily dependent on the
eligible retiree for maintenance and support
 a child for whom the eligible retiree is the legal guardian and who is
primarily dependent on the eligible retiree for maintenance and support, as
long as evidence of the guardianship is provided in a court order or decree
 a foster child living in the same household as the eligible retiree
You must provide a copy of birth certificate(s) and court documents (if applicable) to the NMRHCA.


a dependent child over age 26 who is wholly dependent on the eligible retiree for
maintenance and support and is incapable of self-sustaining employment by reason
of mental or physical handicap. The disability must have occurred before the
limiting age. Proof of incapacity and dependency must be provided within 31 days
after the child reaches the limiting age.
a surviving spouse (the spouse to whom a deceased eligible retiree/vested-active
employee was married at the time of death) or a surviving dependent child of a
deceased eligible retiree/vested-active employee.
ENROLLMENT
 It is best to submit your application at least one month but not to exceed 60 days from
your retirement date to allow adequate time for the agency to process your
application.
 Please be advised it takes a minimum of 3 business weeks for an application to
process.
 You must enroll within 31 days following either your last day of current medical
insurance coverage or your retirement date that is on record with your retirement
board; whichever is later. Your effective date of coverage will take effect on the first
day of your official retirement or the first day of the month following the
termination date of your current medical insurance plan, again, whichever is later.
 If you do not apply within this time frame, you will be required to submit a
NMRHCA Plan Health Statement certifying the state of each applicant’s health.
Approvals will be decided by our medical underwriter’s evaluation of the
applicant’s medical history. If the retiree is denied, then the retiree’s dependents
will not be eligible either. If approved, the underwriter’s will inform you of the
effective date of coverage.
 You may enroll a dependent only under one of the following circumstances: (1)
there is a change in status which makes someone newly eligible as your dependent
(e.g., marriage, birth); (2) an unenrolled eligible dependent involuntarily loses his or
her medical coverage; or (3) upon submission and approval of a Change Request
Form and an NMRHCA Plan Health Statement certifying the state of your
dependent’s health. For newly eligible dependents, you must apply for dependent
coverage within 31 days of the event that caused the new eligibility (copies of
marriage, birth, or court documents required). Late enrollment approvals will be
decided by our medical underwriter’s evaluation of the applicant's medical history.
 In each case above, you will be required to pay the first two months of premiums up
front.
PURCHASING SERVICE CREDIT


In the 2009 legislative session, a bill was passed that requires payment of Retiree
Health Care Authority (RHCA) contributions for service credit purchased from
PERA and ERB toward retirement. Effective July 1, 2009, members who enroll in
RHCA at the time of retirement must pay contributions on the PERA and ERB
service credit before being eligible for insurance coverage.
This contribution provision only affects members who are applying for insurance at
the time of retirement. PERA and ERB will be providing RHCA with verification of
a member’s earned service credit and any purchased credit. RHCA will then
calculate the cost of the RHCA contributions owed on the purchased service
credit. Payment will be required for those retirees with less than 20 years of actual
time worked and are purchasing time toward their retirement after July 1, 2009.
For further information, please contact the NMRHCA office for complete details of
purchasing service credit.
SPLIT COVERAGE

If the retiree is covering a spouse or dependent(s) under their plan, they must have
the same level of benefits as the retiree (with the exception if one of the members in
the household is Medicare eligible and the other member in not Medicare eligible).
For example, if the retiree selects the Premier Plus plan, the spouse or any
dependents covered by the retiree must also be on the Premier Plus plan.
CANCELLATION OF COVERAGE


Subscribers may cancel coverage by submitting written notification to the New
Mexico Retiree Health Care Authority (NMRHCA). Cancellation will take effect
beginning with the first day of the month following receipt of notification by the
NMRHCA. Effective date of cancellation is not retroactive.
If a dependent becomes ineligible through joining the military, death, divorce,
annulment, or legal separation, coverage ceases at the end of the month in which the
event occurred. Again, it is your responsibility to notify us in writing and
supporting documentation may be requested.
RETURN TO WORK

If you take new employment after your retirement or choose to be covered under
your spouse’s coverage, you may choose one of two NMRHCA options:
 Delay or terminate your enrollment in the NMRHCA and take your new
employer's plan or spouse’s plan. Under this option, you will be allowed to
enroll into the NMRHCA at a later date without being required to submit an
NMRHCA Plan Health Statement, if you apply within 31 days of your
involuntary loss of coverage (see below for examples) and there has been no
lapse in your comprehensive medical coverage since your retirement. You
will be required to submit evidence of continuous coverage and involuntary

loss when you apply for NMRHCA enrollment. Examples of involuntary
loss of coverage are (1) termination of your employment; (2) retirement from
your new employer, causing your employer to cancel your health care
benefits; (3) cancellation of your health care benefit program by the employee;
and (4) dissolution of the company.
 Take the new employer's plan of benefits and enroll yourself and your
eligible dependents into the NMRHCA, thus receiving health care benefits
from both plans through the NMRHCA’s and your new employer's insurance
carrier's Coordination of Benefits Provision. Please note that the Retiree
Health Care Act requires that the NMRHCA program of health care benefits
be secondary to your employer's benefit plans. This means your claims will
be paid primarily by your employer's insurance plan, and then the balance
will be considered by your NMRHCA insurance plan.
If your employer does not offer medical coverage, you will need to submit a letter
from your employer verifying that no insurance is offered or available in order for
NMRHCA benefits to remain as primary.
CHANGE IN STATUS
If there is a change in your name, address, phone number, marital status, or dependent
status, or if you wish to request a change in your benefit plans, life insurance beneficiary,
or method of premium contribution payment, please call us immediately or visit our
website to obtain a Change Request Form or submit a letter of request in writing.
NMRHCA
4308 Carlisle Blvd., NE, Suite 104
Albuquerque, NM 87107-4849
1-800-233-2576
NMRHCA
810 West San Mateo, Suite D
Santa Fe, NM 87505-4144
505-476-7340
Website: www.nmrhca.state.nm.us
Hours of operation at both locations are 8 a.m. - 5 p.m., Monday through Friday.
01/2015
Effective Date: January 2015
BCBSNM AND PRESBYTERIAN PPO COMPARISON
NMRHCA NON-MEDICARE PLAN COMPARISON
These plans have no lifetime maximum benefit (except for transplants), though certain services have maximum annual limits.
Retiree Premiums (Based on 20+ years of service,
Premier Plus - $293.79
please refer to rate sheet for Spouse and Dependent
rates)
Premier Plus:
$300/Individual
Premier Plus:
$3,000/Individual
Premier Plus
Retiree Responsibility
Primary -$20
Specialist - $35
Plan pays 100%
Annual Deductible
Annual Out-of-Pocket Limit
Office Services
Office visit not subject to deductible
Preventive Services
Related testing (includes routine Pap test,
mammograms, colonoscopy, physicals, etc.) &
immunization (deductible waived)
Lab, X-Ray, and Pathology
Emergency Room
Emergency Physician and other Professional
Provider Charges
Urgent Care Facility
Ambulance Services
EKG
High-Tech Radiology (MRI, PET & CT)
Rehabilitation Inpatient or Outpatient
Alternative (chiropractic, acupuncture, etc.)
Hospitalization - Inpatient
Surgery - Outpatient
All Other Covered Services (visit phs.org or
bcbsnm.com for full list)
Premier - $157.20
Premier: $800/Individual
Premier: $4,000/Individual
Premier
Retiree Responsibility
Primary -$30
Specialist - $45
Plan pays 100%
Plan pays 100%
Plan pays 100%
Plan pays 100%
$100
Plan pays 100%
$125
20%
25%
$30
20%
20%
20%
20%
20%
20%
20%
$35
25%
25%
25%
25%
25%
25%
25%
20%
25%
NON-MEDICARE PRESCRIPTION DRUG PLAN ADMINISTERED
BY EXPRESS SCRIPTS
Copay (Retail)
Generic
Brand
Brand Non-Formulary
Minimum
$5
$20
$40
Maximum
$15
$50
$100
Maximum of 34-day supply or 100 unit or as prescribed by your physician or an
approved exception.
Copay (Mail Order)
Generic
Preferred Brand
Non-Formulary
Minimum
$12
$50
$100
Maximum
$35
$100
$150
Maximum of 90-day supply or 300 units or as prescribed by your physician or
an approved exception.
Accredo (Special Pharmaceuticals)
Closed Network
For more information visit our website at www.nmrhca.state.nm.us or call us at 1-800-233-2576.
Revised 9/8/2014
Effective: January 2015
NMRHCA MEDICARE PLAN COMPARISON
BCBS Medicare
BCBSNM
MEDICARE SUPPLEMENT Advantage Plan I
RETIREE PREMIUMS Based
on 20+ Years
BENEFIT Highlights
$167.88
$49.75
Part B Annual Deductable:
$147.00 (2014) 2015
Deductible to be
determined.
Annual Out of
Pocket Limit:
$5000
Presbyterian
Medicare
Advantage Plan I
$79.00
United Healthcare
Presbyterian
BCBS Medicare
Medicare Advantage
Medicare Advantage
Advantage Plan II
Plan I
Plan II
$69.55
$14.75
United Healthcare
Medicare Advantage
Plan II
$49.00
Annual Out of
Annual Out of Pocket
Annual Out of
Annual Out of Pocket
Pocket Limit: $2500
Limit: $2500
Pocket Limit: $6700
Limit: $3000
$40.38
Annual Out of Pocket
Limit: $2800
Once Part B Deductible is met
charges for services are as follows:
Office Visit
Primary Care
Specialty care
Preventive services
$0
$0
$0
$10
$35
$0
$10
$30
$0
$5
$25
$0
$10
$40
$0
$10
$40
$0
$5
$25
$0
Hospital Services
$0
$250 per day
1-5
$125 per day
1-3
$250 per admission
$500 per
admission
$225 per day 1-3
$250 per admission
Surgery - hospital outpatient
$0
$200
$125
$100
$350
$225
$100
$0
$0
$65
$40
$65
$10
$50
$20
$65
$50
$65
$10
$50
$20
After Part B Deductible is
met: $0
$0
$0
$0
$0
$0
$0
$4
$10
$45
$95
33%
$10
$20
$20
$35
$35
Emergency Services
Emergency room visit
Urgent care center
Diabetic Supplies
All Other Covered Services (visit phs.org, bcbsnm.com or uhcretiree.com for full list)
$310 Deductible
Retail Pharmacy - 30-day
Preferred Generic
Non-Preferred Generic
Preferred Brand
Non-Preferred Brand
Specialty Drug
Non-Formulary
Mail Order - 90 day
$5 - $15
$20 - $50
$40- $100
$0
$5
$40
$90
33%
$2
$8
$20
$45
25%
$10
$20
$20
$35
$35
$0
$7
$40
$90
25%
Preferred Generic
$12 - $35
$0
$6
$20
$0
$12
$20
Non-Preferred Generic
$15
$24
$40
$21
$30
$40
Preferred Brand
$50 - $100
$135
$60
$40
$126
$135
$40
Non-Preferred Brand
$270
$135
$70
$285
$285
$70
Non - Formulary
$100 - $150
Prescription Coverage Gap
Coverage Gap
No
No
No
No
No
Yes
Yes
Catastrophic Level Coverage Changes: After your out-of-pocket drug costs reach $4,700 for the year, then you pay the greater of: $2.60 for formulary generic or a formulary brand drug
and $6.50 for all other drugs, or 5% coinsurance.
This is a summary for your convenience. Please contact Blue Cross Blue Shield, Presbyterian or United Healthcare directly for a full list of benefits.
Revised 12/5/2014
NMRHCA 2015 Dental Plan Comparison
UNITED CONCORDIA DENTAL
BENEFIT CATEGORY
Diagnostic and Preventive Services
BASIC PLAN
In-Network
Plan Pays
Out-ofNetwork
Plan Pays
DELTA DENTAL - PPONEW MEXICO NETWORK
COMPREHENSIVE PLAN
In-Network
Plan Pays
Out-of-Network
Plan Pays
Routine Oral Exams
(three per 12 months)
Routine Cleanings
(three per 12 months)
X-rays (complete mouth-once every 5 years;
bitewings two sets per 12 months through age
13 once every 12 months thereafter)
100%
No Deductible
25% of
Allowed
Amount
100%
No Deductible
100% of
Allowed Amount
No Deductible
Emergency Treatment for Relief of Pain
BENEFIT CATEGORY
Diagnostic and Preventive Services
Oral Exams
(two routine per calendar year plus one
problem-focused/emergency, if needed.)
Routine Cleanings
(two per calendar year)
Basic Services
Amalgam or Composite Fillings
80%
Endodontics
25%
of Allowed
Amount
Stainless Steel Crowns
80%
Not Covered
55% of
Allowed Amount
Out-of-Network
Plan Pays
75% of
Allowed Amount
No Deductible
25%
of Allowed
Amount
80%
55% of
Allowed Amount
Not Covered
50%
35% of
Allowed Amount
Not Covered
50%
No Deductible
$1000 Lifetime
Max
50% of
Allowed Amount
No Deductible
$500 Lfetime Max
Not Covered
Surgical and Non-surgical Periodontics
80%
25% of
Allowed
Amount
Repairs to Crowns, Onlays, Dentures and
Bridgework
Major Services
Prosthodontic procedures for contruction of
fixed bridges, partials or complete dentures
Not Covered
50%
35% of
Allowed Amount
Implants - specified services, including
repairs, and related prosthodontics, subject to
clinical review/approval
Onlays and Crowns (when teeth cannot be
restored to normal form and function with
amalgam, composite resin or plastic fillings)
Onlays, Crowns and Cast Restorations - when
teeeth cannot be restorted with amalgam or
composite resin restorations
Orthodontics
Orthodontics
Not Covered
50%
No Deductible
$1000 Lifetime
Max
50% of
Allowed Amount
No Deductible
$500 Lfetime Max
Diagnostic, Active, Retention Treatment
In and out-of-network lifetime maximums
cannot be combined.
Deductibles and Maximums
Deductibles and Maximums
Calendar Year Deductible - Jan 1 thru Dec 31.
Applies to all services except where noted
above.
Calendar Year Deductible - Jan 1 thru Dec 31.
Applies to all services except where noted
above.
Calendar Year Maximum - Jan 1 thru Dec 31
(per person). In and out-of-network annual
maximums cannot be combined.
In-Network
Plan Pays
25% of
100%
Allowed
No Deductible
Amount
No Deductible
Oral Surgery (including surgical extractions)
Major Services
Diagnostic, Active, Retention Treatment
In and out-of-network lifetime maximums
cannot be combined.
COMPREHENSIVE PLAN
Endodontics
Removeable Partial or Complete Dentures and
Fixed Bridges
Implants and Implant Related Services
80%
Simple Extractions (non-surgical)
Nonsurgical Periodontics
Repair to Onlays, Crowns, Dentures and
Bridgework
100%
No Deductible
Out-ofNetwork
Plan Pays
Emergency Treatment for Relief of Pain
Basic Restorative (amalgam allowance for
posterior teeth)
Complex Oral Surgery
(covered on Comprehensive Plan only)
Surgical Periodontics
(covered on Comprehensive Plan only)
In-Network
Plan Pays
X-rays (full mouth-once every 5 years;
bitewings twice in a calendar year)
Basic Services
Simple Extractions
BASIC PLAN
$50 ($150 Per Family)
$1,500.00
$50 ($150 per family)
$1,500.00
$1,000.00
Calendar Year Maximum - Jan 1 thru Dec 31
(per person). In and out-of-network annual
maximums cannot be combined.
80%
25% of
Allowed
Amount
$50 ($150 Per Family)
$1,500.00
$1,500.00
$50 ($150 per family)
$1,500.00
$1,000.00
Important Note: Lowest out-of-pocket costs apply In-Network. Non-Participating Providers may balance bill patients for charges over the allowed amount (up to the full amount of submitted charges).
This Benefit Comparison has been prepared as a general description to highlight some of the benefits available under your dental plan options.
It does not reflect all benefits, limitations, exclusions, or provide complete coverage information. Complete coverage descriptions are provided by the dental plan carrier when you enroll.
Revised 9/30/2014
Davis Vision 2015 Benefits
BENEFIT CATEGORY
Routine Eye Examinations
Every 12 months
Eye Glasses
Spectacle Lenses
Every 12 months
Frames
Contact Lenses
Every 24 months
Every 12 months
In-Network Coverage
Copay
$10
Out-of-Network Coverage
Reimbursed up to
$35
Copay
$15
Copay $15
(Davis frame collection)
Allowance
Up to $110 Non-Formulary
Plus 15% discount on overage
Medically necessary paid in full
Prior approval required
Depending on Lens RX
$25 to $80
Reimbursed up to
$35
Allowance
Up to $110 (elective)
Up to $210 (medically necessary)
This is a summary for your convenience. For more information visit our website at www.nmrhca.state.nm.us or call us at 1-800-233-2576
NMRHCA Medical Plan Monthly Premium Contributions for January 1, 2015 ‐ December 31, 2015 (applicable if retirement date is after June 30, 2001)
Years of Service
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20+
NON‐MEDICARE MEDICAL
Premier Plus (BCBS or Presbyterian)
Retiree Rate
Spouse Rate
Child Rate*
Premier (BCBS or Presbyterian)
Retiree Rate
Spouse Rate
Child Rate*
$805.31
$771.21
$737.11
$703.01
$668.90
$634.80
$600.70
$566.60
$532.50
$498.40
$464.30
$430.20
$396.09
$361.99
$327.89
$293.79
$729.48
$711.74
$693.99
$676.24
$658.50
$640.75
$623.00
$605.26
$587.51
$569.76
$552.01
$534.27
$516.52
$498.77
$481.03
$463.28
$288.04
$288.04
$288.04
$288.04
$288.04
$288.04
$288.04
$288.04
$288.04
$288.04
$288.04
$288.04
$288.04
$288.04
$288.04
$288.04
$430.89
$412.65
$394.40
$376.16
$357.91
$339.66
$321.42
$303.17
$284.92
$266.68
$248.43
$230.19
$211.94
$193.69
$175.45
$157.20
$468.11
$456.72
$445.34
$433.95
$422.56
$411.17
$399.78
$388.40
$377.01
$365.62
$354.23
$342.84
$331.45
$320.07
$308.68
$297.29
$156.68
$156.68
$156.68
$156.68
$156.68
$156.68
$156.68
$156.68
$156.68
$156.68
$156.68
$156.68
$156.68
$156.68
$156.68
$156.68
$325.28
$314.78
$304.29
$293.80
$283.30
$272.81
$262.32
$251.83
$241.33
$230.84
$220.35
$209.85
$199.36
$188.87
$178.37
$167.88
$330.52
$325.28
$320.03
$314.79
$309.54
$304.29
$299.05
$293.80
$288.55
$283.31
$278.06
$272.82
$267.57
$262.32
$257.08
$251.83
$335.77
$335.77
$335.77
$335.77
$335.77
$335.77
$335.77
$335.77
$335.77
$335.77
$335.77
$335.77
$335.77
$335.77
$335.77
$335.77
$96.39
$93.28
$90.17
$87.06
$83.95
$80.84
$77.73
$74.63
$71.52
$68.41
$65.30
$62.19
$59.08
$55.97
$52.86
$49.75
$97.95
$96.39
$94.84
$93.28
$91.73
$90.17
$88.62
$87.06
$85.51
$83.95
$82.40
$80.84
$79.29
$77.73
$76.18
$74.62
$99.50
$99.50
$99.50
$99.50
$99.50
$99.50
$99.50
$99.50
$99.50
$99.50
$99.50
$99.50
$99.50
$99.50
$99.50
$99.50
$28.58
$27.66
$26.73
$25.81
$24.89
$23.97
$23.05
$22.13
$21.20
$20.28
$19.36
$18.44
$17.52
$16.59
$15.67
$14.75
$29.04
$28.58
$28.12
$27.66
$27.19
$26.73
$26.27
$25.81
$25.35
$24.89
$24.43
$23.97
$23.50
$23.04
$22.58
$22.12
$29.50
$29.50
$29.50
$29.50
$29.50
$29.50
$29.50
$29.50
$29.50
$29.50
$29.50
$29.50
$29.50
$29.50
$29.50
$29.50
$153.06
$148.13
$143.19
$138.25
$133.31
$128.38
$123.44
$118.50
$113.56
$108.63
$103.69
$98.75
$93.81
$88.88
$83.94
$79.00
$155.53
$153.06
$150.59
$148.13
$145.66
$143.19
$140.72
$138.25
$135.78
$133.31
$130.84
$128.38
$125.91
$123.44
$120.97
$118.50
$158.00
$158.00
$158.00
$158.00
$158.00
$158.00
$158.00
$158.00
$158.00
$158.00
$158.00
$158.00
$158.00
$158.00
$158.00
$158.00
$94.94
$91.88
$88.81
$85.75
$82.69
$79.63
$76.56
$73.50
$70.44
$67.38
$64.31
$61.25
$58.19
$55.13
$52.06
$49.00
$96.47
$94.94
$93.41
$91.88
$90.34
$88.81
$87.28
$85.75
$84.22
$82.69
$81.16
$79.63
$78.09
$76.56
$75.03
$73.50
$98.00
$98.00
$98.00
$98.00
$98.00
$98.00
$98.00
$98.00
$98.00
$98.00
$98.00
$98.00
$98.00
$98.00
$98.00
$98.00
$134.75
$130.41
$126.06
$121.71
$117.37
$113.02
$108.67
$104.33
$99.98
$95.63
$91.28
$86.94
$82.59
$78.24
$73.90
$69.55
$136.93
$134.75
$132.58
$130.41
$128.23
$126.06
$123.88
$121.71
$119.54
$117.36
$115.19
$113.02
$110.84
$108.67
$106.49
$104.32
$139.10
$139.10
$139.10
$139.10
$139.10
$139.10
$139.10
$139.10
$139.10
$139.10
$139.10
$139.10
$139.10
$139.10
$139.10
$139.10
$78.24
$75.71
$73.19
$70.67
$68.14
$65.62
$63.09
$60.57
$58.05
$55.52
$53.00
$50.48
$47.95
$45.43
$42.90
$40.38
$79.50
$78.24
$76.97
$75.71
$74.45
$73.19
$71.93
$70.67
$69.40
$68.14
$66.88
$65.62
$64.36
$63.09
$61.83
$60.57
$80.76
$80.76
$80.76
$80.76
$80.76
$80.76
$80.76
$80.76
$80.76
$80.76
$80.76
$80.76
$80.76
$80.76
$80.76
$80.76
MEDICARE MEDICAL
BCBS Medicare Supplemental Plan
Retiree Rate
Spouse Rate
Child Rate*
BCBS Medicare Advantage I
Retiree Rate
Spouse Rate
Child Rate*
BCBS Medicare Advantage II
Retiree Rate
Spouse Rate
Child Rate*
Presbyterian Medicare Advantage I
Retiree Rate
Spouse Rate
Child Rate*
Presbyterian Medicare Advantage II
Retiree Rate
Spouse Rate
Child Rate*
United Healthcare Medicare Advantage I
Retiree Rate
Spouse Rate
Child Rate*
United Heathcare Medicare Advantage II
Retiree Rate
Spouse Rate
Child Rate*
*Multiple Child Subsidy may apply.
Medical Plan Rate Calculation Instructions
$_________ Retiree
1. Select a medical plan for the retiree; enter the rate from the Retiree Rate row that corresponds with your years of service.
2. If you are enrolling your spouse, select a medical plan for him/her; enter the rate from the Spouse Rate row that corresponds
with your years of service (or, if your spouse is also an NMRHCA-eligible retiree, use the Retiree Rate that corresponds with
your spouse’s years of service).
+ $_________ Spouse
3. If you are also enrolling children, enter rate from Child Rate row once for the first child. For each additional child, enter the
Child Rate multiplied by 0.750. (# of additional children: ____ x Child Rate: ______ x 0.750 = Total for Additional Child(ren): ______
If multiple children are to be covered without a spouse, please contact NMRHCA for assistance with calculating the rate.
+ $_________ 1st Child
+ $_________ Additional Child(ren)
4. TOTAL #1, #2, and #3.
= $_________ Total
Voluntary Coverage Premiums
DENTAL PLAN Monthly Premium*: Effective January 1, 2015 to December 31, 2015 SINGLE
$17.85
$39.85
$17.49
$35.70
Delta Dental Basic Delta Dental Comprehensive United Concordia Basic United Concordia Comprehensive TWO-PARTY
$33.48 for both
$75.72 for both
$33.23 for both
$67.82 for both
FAMILY
$ 56.08 for all
$122.23 for all
$ 49.85 for all
$101.70 for all
VISION PLAN Monthly Premium*: Effective July 1, 2012 to December 31, 2015 Davis Vision $ 4.76
$13.23 for all
$ 8.98 for both
DEPENDENT CHILD LIFE Monthly Premium*: Effective January 1, 2008 to December 31, 2015 $2,500 - $3.83 for all
The Standard Insurance $5,000 - $7.15 for all
$10,000 - $13.80 for all
RETIREE/SPOUSE SUPPLEMENTAL LIFE Monthly Premium*: Effective January 1, 2008 to December 31, 2015 The Standard Age 35‐39 Age 40‐44 Age 45‐49 Age 50‐54 Age 55‐59 Age 60‐64 Age 65‐69 Age 70 and over $2,000
$ 0.70
$ 0.81
$ 1.07
$ 1.42
$ 2.03
$ 2.36
$ 4.32
$ 6.36
$4,000
$ 0.89
$ 1.13
$ 1.64
$ 2.34
$ 3.56
$ 4.22
$ 8.14
$12.22
$6,000
$ 1.09
$ 1.44
$ 2.20
$ 3.27
$ 5.08
$ 6.09
$11.97
$18.08
$8,000
$ 1.28
$ 1.76
$ 2.77
$ 4.19
$ 6.61
$ 7.95
$15.79
$23.94
$10,000
$ 1.48
$ 2.07
$ 3.34
$ 5.11
$ 8.14
$ 9.81
$19.61
$29.80
$15,000**
$ 1.97
$ 2.86
$ 4.76
$ 7.42
$11.96
$14.47
$29.17
$44.45
$20,000**
$ 2.46
$ 3.64
$ 6.18
$ 9.72
$15.78
$19.12
$38.72
$59.10
$40,000**
$ 4.42
$ 6.78
$ 11.86
$ 18.94
$ 31.06
$ 37.74
$ 76.94
$117.70
$46,000**
$ 5.01
$ 7.72
$ 13.56
$ 21.71
$ 35.64
$ 43.33
$ 88.41
$135.28
$60,000**
$ 6.38
$ 9.92
$ 17.54
$ 28.16
$ 46.34
$ 56.36
$115.16
$176.30
*The life plan rates include a $.50 administration fee. This is optional coverage, and the entire cost of coverage is paid by you. Cost of insurance for all coverages paid by you may increase or decrease in the future based upon the claims experience of participants. All provisions that apply to this coverage are governed by the Certificate. **Evidence of Insurability Statement required to add or increase life insurance. The form can be found at http://www.standard.com/mybenefits/newmexico_rhca.