2022 Summary of Benefits
Medical

--- 






--- 
-- 
--- 

--- 
-- 
--- 

--- 



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

--- 
--

--- 


-


Prescription Drug (For all Non Medicare Plans and BCBS Supplemental Medicare)

 -
---
-
---
Dental

--- 
-- 
-

Vision

--- 
 
 
Life Insurance
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--- 
-- 


Provider Contact List
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---
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IMPORTANT INFORMATION YOU NEED TO KNOW
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.
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.org)
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.
If you are enrolling more than 31 days after retirement underwriting approval for Life
Insurance is required.
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 wait until the next Open
Enrollment period.
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) during an Open Enrollment Period. 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).
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 plan, the spouse or any dependents covered by the retiree must also be
on the Premier 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, 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.
Plan Terms and Definitions
1. Annual Deductible – means the amount that must be paid (by you) each calendar year, toward covered services
before health benefits for that member will be paid by the plan (except for certain services requiring only a
copayment with deductible waived or preventive services).
2. Annual Out-of-Pocket Limit – means a specified dollar amount of covered services received during a benefit
period that is the member’s responsibility; after which the out-of-pocket limit is reached the plan pays 100 percent
of benefits for the rest of the calendar year for covered charges.
3. Calendar Year (also referred to as benefit period) – means the period beginning January 1 and ending December
31 of the same year.
4. Coinsurance – means the amount, expressed as a percentage, of a covered health care expense that is partially
paid by the plan and partially the member’s responsibility to pay. The cost-sharing responsibility ends for most
covered services in a particular calendar year when the out-of-pocket maximum has been reached.
5. Copayment or Copay – means the amount, expressed as a fixed-dollar figure required to be paid by a member in
connection with health care services. Benefits payable by the plan are reduced by the amount of the required
copayment for the covered service.
6. Coverage GAP (also referred to as donut hole) – is a period of consumer payment for prescription medication
costs, which lies between the initial coverage limit and the catastrophic-coverage threshold. The Coverage GAP
only applies to Medicare Part D prescription drug coverage.
7. HMO (Health Maintenance Organization) – you can only go to doctors, other health care providers, or hospitals
on the plan's list except in an emergency or when treatment is not available through an in-network provider.
8. In-Network Provider – means physicians, hospitals, and other health care professionals, facilities, and suppliers
that have contracted with the health plan as in-network providers.
9. Medicare – means the program of health care for the aged, end-stage renal disease (ESRD) patients and disabled
persons established by Title XVIII of the Social Security Act of 1965, as amended.
10. Medicare Advantage Plan – Sometimes called Medicare Part C. A plan offered by a private company that
contract with Medicare to provide you with all your Medicare Part A and Part B benefits.
11. Medicare Supplemental Plan – means health care coverage that provides supplemental benefits to Medicare
coverage.
12. Out-of-Network Provider – means a duly licensed health care provider, including medical facilities, which has
no agreement with the health plan for reimbursement of services to members.
13. PPO (Preferred Provider Organization) – a type of health plan that lets you choose where you go for care, without
a referral from a primary care physician or having to only use providers in your plan's provider network.
NMRHCA NMRHCA
6300 Jefferson St NE, Suite 150 33 Plaza La Prensa, Suite 101
Albuquerque, NM 87109 Santa Fe, NM 87507
1-800-233-2576 505-476-7340
Website: www.nmrhca.org
Hours of operation at both locations are 8 a.m. - 5 p.m., Monday through Friday.
In Network Out of Network
Primary - $30 50%
Specialist - $45 50%
Preventive Services
Plan pays 100% 50%
Related testing (includes routine Pap test, mammograms,
colonoscopy, physicals, etc.) & immunization (deductible waived)
Plan pays 100% 50%
Lab, X-Ray, and Pathology
Plan pays 100% 50%
Emergency Room $125 $125
Emergency Physician and other Professional
Provider Charges
25% 25%
Urgent Care Facility $35 50%
Ambulance Services (Emergency) 25% 25%
EKG 25% 50%
High-Tech Radiology (MRI, PET & CT)
Office/Freestanding Radiology
$100 50%
High-Tech Radiology (MRI, PET & CT) Outpatient
Department of Hospital
25% 50%
Rehabilitation Outpatient
Physical Therapy Services when used as alternative to surgery
(Max of 4 copays per course of treatment)
$30 50%
Rehabilitation Outpatient $30 50%
Rehabilitation Inpatient 25% 50%
Alternative (chiropractic, acupuncture, etc.; $1500
benefit limit)
25% 50%
Hospitalization - Inpatient 25% 50%
Surgery - Outpatient 25% 50%
*Outpatient Bundled Procedures (Bundled services:
shoulder arthroscopy, knee arthroscopy, laparoscopic
cholecystectomy, hernia)
$500 N/A
All Other Covered Services (visit phs.org full list) 25% 50%
Copay (Retail) Minimum Maximum
Generic $5 $15
Preferred Brand $30 $60
Non-Preferred Brand $50 $125
Copay **(Mail Order or Smart 90) Minimum Maximum
Generic $12 $35
Preferred Brand $60 $120
Non-Preferred Brand $100 $250
Accredo (Special Pharmaceuticals)
For more information visit our website at www.nmrhca.org or call us at 1-800-233-2576.
* Please contact Presbyterian Health Plan at 1-888-275-7737 for participating facilities.
Maximum of 34-day supply or 100 unit or as prescribed by your physician or an approved exception.
Maximum of 90-day supply or 300 units or as prescribed by your physician or an approved exception.
Closed Network
NON-MEDICARE PRESCRIPTION DRUG PLAN ADMINISTERED BY EXPRESS SCRIPTS
Pre-Medicare plan members on specialty medications through Express Scripts' Accredo specialty pharmacy may receive copay assistance through the Save On SP program.
Members identified as taking specific medications that qualify for the Save On SP program will be contacted directly by Save On SP to see if they would like to participate. By
participating in the program, members will save money on their specialty prescriptions with this copay assistance program. To find out more about this specialty prescription
drug benefit, please call Save On SP at 1-800-683-1074.
EFFECTIVE: JANUARY 1, 2022
NMRHCA PRESBYTERIAN HEALTH PLAN (PHP) NON-MEDICARE PLAN COMPARISON
Member Responsibility
Annual Deductible
$800/Individual
PHP Premier PPO
Annual Out-of-Pocket Limit
$4,500/Individual
Office Services
Office visit not subject to deductible
Revised 9/13/2021
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 (Emergency)
EKG
High-Tech Radiology (MRI, PET &
CT) Office/Freestanding Radiology
High-Tech Radiology (MRI, PET &
CT) Outpatient Department of Hospital
Rehabilitation Outpatient
Physical Therapy Services when used as
alternative to surgery (Max of 4 copays per course
of treatment)
Rehabilitation Outpatient
Rehabilitation Inpatient
Alternative (chiropractic, acupuncture,
etc.; $1500 benefit limit)
Hospitalization - Inpatient
Surgery - Outpatient
All Other Covered Services (visit
bcbsnm.com for full list)
Copay (Retail)
Generic
Preferred Brand
Non-Preferred Brand
Copay **(Mail Order or Smart 90)
Generic
Preferred Brand
Non-Preferred Brand
Accredo (Special Pharmaceuticals)
For more information visit our website at www.nmrhca.org or call us at 1-800-233-2576.
Pre-Medicare plan members on specialty medications through Express Scripts' Accredo specialty pharmacy may receive copay assistance through the Save On SP program.
Members identified as taking specific medications that qualify for the Save On SP program will be contacted directly by Save On SP to see if they would like to participate.
By participating in the program, members will save money on their specialty prescriptions with this copay assistance program. To find out more about this specialty
prescription drug benefit, please call Save On SP at 1-800-683-1074.
$120
$250
** Long-term medications can be filled for a 90-day
supply at your local Walgreens pharmacy or
through home delivery from Express Scripts
Pharmacy. Visit www.express-scripts.com or call
Express Scripts at 1-800-501-0987 for more
information.
Maximum of 90-day supply or 300 units or as prescribed by your physician or an approved exception.
Closed Network
$100
NON-MEDICARE PRESCRIPTION DRUG PLAN ADMINISTERED BY EXPRESS SCRIPTS
Minimum
$5
$30
$50
Maximum
$15
$60
$125
Maximum of 34-day supply or 100 unit or as prescribed by your physician or an approved exception.
Minimum
$12
$60
$35
Maximum
50%
Plan pays 100%
Plan pays 100%
$20
50%
50%
50%
50%
10%
25%
10%
25%
10%
25%
10%
25%
$30
10%
25%
25%
10%
25%
$100
$100
Annual Deductible
$500/Individual
$800/Individual
Annual Out-of-Pocket Limit
$3,000/Individual
$4,500/Individual
Office Services
Office visit not subject to deductible
Primary - $20
Primary - $30
Specialist - $35
Specialist - $45
Specialist - 50%
50%
25%
$35
Plan pays 100%
$125
25%
10%
25%
Plan pays 100%
$125
10%
$35
Tier 2 - Preferred
Plan pays 100%
Plan pays 100%
30%
$125
30%
50%
50%
$125
25%
50%
25%
Plan pays 100%
$175
30%
$40
50%
50%
Tier 3 - Out of Network
$1,500/Individual
$6,000/Individual
50%
50%
Primary - 50%
NMRHCA BLUE CROSS BLUE SHIELD(BCBS) NON-MEDICARE PLAN COMPARISON
EFFECTIVE: JANUARY 1, 2022
30%
30%
30%
HMO
$1,500/Individual
$5,500/Individual
Primary - $35
30%
30%
30%
$20
$30
50%
$35
$35
Plan pays 100%
Member Responsibility
BCBS Premier 3 Tier PPO
BCBS Value
Specialist - $55
Plan pays 100%
Tier 1 - Blue Preferred
Revised 9/13/2021
BENEFIT Highlights
Part B Annual
Deductible: $233.00
Annual Out of
Pocket Limit:
$3000
Annual Out of
Pocket Limit:
$2500
Annual Out of
Pocket Limit:
$2500
Annual Out of
Pocket Limit:
$3500
Annual Out of
Pocket Limit:
$6700
Annual Out of
Pocket Limit:
$3000
Annual Out of
Pocket Limit:
$2800
Annual Out of
Pocket Limit:
$1500
Office Visit
Primary Care
$0 $10
$10
$5 $5 $10 $10 $5 $2
Specialty care
$0 $30
$30
$25 $30 $40 $40 $25 $25
Preventive services
$0 $0 $0 $0 $0 $0 $0 $0 $0
Hospital Services
$0
$125 per day
Days 1-5
$125 per day
Days 1-3
$250 per
admission
$150 per day
Days 1-5
$500 per
admission
$225 per day
Days 1-5
$250 per
admission
$200 per
admission
Surgery - hospital
outpatient
$0
$175 $125 $100 $150 $300 $275 $100 $125
Emergency Services
Emergency room visit
$0
$65 $65 $50 $50 $90 $75 $50 $65
Urgent care center
$0
$25 $10 $20 $20 $50 $10 $20 $10
Diabetic Supplies
$0
$0 $0 $0 $0 $0 $0 $0 $0
Preferred Generic
$5 - $15
$0 - $5 $0 $15 $4 $0 - $5 $0 $10 $4
Non-Preferred Generic
$5 - $10 $10 $70 $4 $7 - $12 $10 $35 $4
Preferred Brand
$30 - $60
$40 - $45 $45 $35 $40 $40 - $45 $45 $20 $20
Non-Preferred Brand
$90 - $95 $95 $70 $90 $90 - $95 $95 $35 $90
Specialty Drug
33% 33% up to $100 $70 25% 25% 27% $35 $125
Non-Formulary
$50 - $125
Mail Order - 90 day***
Preferred Generic
$12 - $35***
$0 - $15 $0 $30 $0 $0 - $15 $0 $20 $0
Non-Preferred Generic
$15 - $30 $20 $140 $0 $21 - $36 $20 $70 $0
Preferred Brand
$60 - $120***
$120 - $135 $112.50 $70 $80 $120 - $135 $112.50 $40 $40
Non-Preferred Brand
$270 - $285 $285 $140 $180 $270 - $285 $285 $70 $180
Non - Formulary
$100 - $250***
Prescription Coverage
Gap
Coverage Gap
No No No No No No
Yes** Yes** Yes**
*** Long-term medications can be filled for a 90-day supply at your local Walgreens pharmacy or through home delivery from Express Scripts Pharmacy. Visit www.express-scripts.com or call Express
Scripts at 1-800-551-1866 for more information.
Catastrophic Level Coverage Changes: After your out-of-pocket drug costs reach $7,050 for the year, then you pay the greater of: $3.95 for generics and $9.85 for brand name drugs or 5% coinsurance.
**Plans with Coverage Gap (a.k.a. Donut Hole). Please ensure you have reviewed & understand how plans work. Plan changes are limited to IRS approved qualifying events (i.e., marriage, divorce,
etc.).
Retail Pharmacy - 31-day
NMRHCA MEDICARE PLAN COMPARISON
Effective: January 1, 2022
Humana
Medicare
Advantage Plan II
All Other Covered Services (visit phs.org, bcbsnm.com, uhcretiree.com/nmrhca, our.humana.com/nmrhca/ for full list)
Humana
Medicare
Advantage Plan I
BCBS Medicare
Advantage Plan II
Presbyterian
Medicare
Advantage Plan II
UnitedHealthcare
Medicare
Advantage Plan II
BCBSNM
MEDICARE
SUPPLEMENT
BCBS Medicare
Advantage Plan I
Presbyterian
Medicare
Advantage Plan I
UnitedHealthcare
Medicare
Advantage Plan I
Revised: 12/13/2021
NMRHCA 2022 Dental and Vision
BENEFIT CATEGORY BENEFIT CATEGORY
In-Network Coverage Out-of-Network Coverage
Diagnostic and Preventive Services
In-Network
Plan Pays
Out-of-
Network
Plan Pays
In-Network
Plan Pays
Out-of-Network
Plan Pays
Routine Eye
Examinations
Every 12 months
Copay Reimbursed up to
Oral Exams
(two routine per calendar year plus one problem-
focused/emergency, if needed.)
$10 $35
Routine Cleanings (three per calendar year and one
additional for specified at-risk medical conditions)
Eye Glasses
Spectacle Lenses
Every 12 months
Copay Depending on Lens RX
$15 $25 to $80
Frames
Every 24 months
Davis Frame Collection Reimbursed up to
Emergency Treatment for Relief of Pain
covered in Full $35
Basic Services
or
Basic Restorative (amalgam or composite fillings)
$100 Retail Frame Allowance or
Simple Extractions (non-surgical)
$150 Retail Frame Allowance at
Endodontics
Visionworks
Nonsurgical Periodontics
Contact Lenses
Every 12 months
Allowance Allowance
Oral Surgery (including surgical extractions)
Up to $110 Non-Formulary Up to $110 (elective)
Surgical Periodontics
Plus 15% discount on overage
Repairs to Crowns, Onlays, Dentures and Bridgework
80%
25% of
Allowed
Amount
Medically necessary paid in full
Major Services
Prior approval required
Prosthodontic procedures for construction of fixed bridges,
partials or complete dentures
Implants - specified services, including repairs, and related
prosthodontics, subject to clinical review/approval
Onlays, Crowns and Cast Restorations - when teeth cannot
be restored with amalgam or composite resin restorations
Orthodontics
Diagnostic, Active, Retention Treatment
In and out-of-network lifetime maximums
cannot be combined.
50%
No Deductible
$1000 Lifetime
Max
50% of
Allowed Amount
No Deductible
$500 Lifetime Max
Deductibles and Maximums
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.
$1,500.00 $1,500.00 $1,500.00 $1,000.00
Radiographic images (full mouth-once every 5 years;
bitewings twice in a calendar year)
50%
55% of
Allowed Amount
80%
100%
No Deductible
BASIC PLAN
COMPREHENSIVE PLAN
35% of
Allowed Amount
$50 ($150 per family)
Not Covered
$50 ($150 Per Family)
100%
No Deductible
80%
75% of
Allowed Amount
No Deductible
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.
DAVIS VISION
Up to $210 (medically necessary)
This is a summary for your convenience. For more information visit our website at www.nmrhca.org or call
us at 1-800-233-2576
Not Covered
25% of
Allowed
Amount
No Deductible
25%
of Allowed
Amount
Not Covered
DELTA DENTAL - POINT-OF-SERVICE NETWORK
Revised 8/25/2021
Years of Service
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25+
NON-MEDICARE MEDICAL
Premier PPO (BCBS or Presbyterian)
Retiree Rate $836.33 $810.04 $783.75 $757.46 $731.17 $704.88 $678.59 $652.30 $626.01 $599.72 $573.44 $547.15 $520.86 $494.57 $468.28 $441.99 $415.70 $389.41 $363.12 $336.83 $310.54
Spouse Rate $905.17 $889.38 $873.60 $857.81 $842.02 $826.23 $810.44 $794.66 $778.87 $763.08 $747.29 $731.50 $715.71 $699.93 $684.14 $668.35 $652.56 $636.77 $620.99 $605.20 $589.41
Child Rate $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43
Value HMO (BCBS or Presbyterian)
Retiree Rate $653.29 $632.76 $612.22 $591.69 $571.15 $550.62 $530.08 $509.54 $489.01 $468.47 $447.94 $427.40 $406.87 $386.33 $365.79 $345.26 $324.72 $304.19 $283.65 $263.12 $242.58
Spouse Rate $707.03 $694.70 $682.36 $670.03 $657.70 $645.37 $633.04 $620.70 $608.37 $596.04 $583.71 $571.38 $559.05 $546.71 $534.38 $522.05 $509.72 $497.39 $485.05 $472.72 $460.39
Child Rate $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06
MEDICARE MEDICAL
BCBS Medicare Supplemental Plan
Retiree Rate $460.92 $449.68 $438.43 $427.19 $415.95 $404.71 $393.47 $382.22 $370.98 $359.74 $348.50 $337.26 $326.02 $314.77 $303.53 $292.29 $281.05 $269.81 $258.56 $247.32 $236.08
Spouse Rate $466.54 $460.92 $455.30 $449.68 $444.06 $438.43 $432.81 $427.19 $421.57 $415.95 $410.33 $404.71 $399.09 $393.47 $387.85 $382.22 $376.60 $370.98 $365.36 $359.74 $354.12
Child Rate $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16
BCBS Medicare Advantage I
Retiree Rate $43.93 $42.86 $41.79 $40.71 $39.64 $38.57 $37.50 $36.43 $35.36 $34.29 $33.21 $32.14 $31.07 $30.00 $28.93 $27.86 $26.79 $25.71 $24.64 $23.57 $22.50
Spouse Rate $44.46 $43.93 $43.39 $42.86 $42.32 $41.79 $41.25 $40.71 $40.18 $39.64 $39.11 $38.57 $38.04 $37.50 $36.96 $36.43 $35.89 $35.36 $34.82 $34.29 $33.75
Child Rate $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00
BCBS Medicare Advantage II
Retiree Rate $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Spouse Rate $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Child Rate $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Humana Medicare Advantage I
Retiree Rate $86.16 $84.06 $81.96 $79.85 $77.75 $75.65 $73.55 $71.45 $69.35 $67.25 $65.14 $63.04 $60.94 $58.84 $56.74 $54.64 $52.54 $50.43 $48.33 $46.23 $44.13
Spouse Rate $87.21 $86.16 $85.11 $84.06 $83.01 $81.95 $80.90 $79.85 $78.80 $77.75 $76.70 $75.65 $74.60 $73.55 $72.50 $71.44 $70.39 $69.34 $68.29 $67.24 $66.19
Child Rate $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26
Humana Medicare Advantage II
Retiree Rate $11.27 $10.99 $10.72 $10.44 $10.17 $9.89 $9.62 $9.34 $9.07 $8.79 $8.52 $8.24 $7.97 $7.69 $7.42 $7.14 $6.87 $6.59 $6.32 $6.04 $5.77
Spouse Rate $11.40 $11.26 $11.13 $10.99 $10.85 $10.71 $10.58 $10.44 $10.30 $10.16 $10.03 $9.89 $9.75 $9.61 $9.48 $9.34 $9.20 $9.06 $8.93 $8.79 $8.65
Child Rate $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54
Presbyterian Medicare Advantage I
Retiree Rate $121.34 $118.38 $115.42 $112.46 $109.50 $106.54 $103.58 $100.62 $97.66 $94.70 $91.75 $88.79 $85.83 $82.87 $79.91 $76.95 $73.99 $71.03 $68.07 $65.11 $62.15
Spouse Rate $122.82 $121.34 $119.86 $118.38 $116.90 $115.42 $113.94 $112.46 $110.98 $109.50 $108.02 $106.54 $105.06 $103.58 $102.10 $100.62 $99.14 $97.66 $96.18 $94.70 $93.22
Child Rate $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30
Presbyterian Medicare Advantage II
Retiree Rate $94.50 $92.19 $89.89 $87.58 $85.28 $82.97 $80.67 $78.36 $76.06 $73.75 $71.45 $69.14 $66.84 $64.53 $62.23 $59.92 $57.62 $55.31 $53.01 $50.70 $48.40
Spouse Rate $95.65 $94.50 $93.34 $92.19 $91.04 $89.89 $88.73 $87.58 $86.43 $85.28 $84.12 $82.97 $81.82 $80.67 $79.51 $78.36 $77.21 $76.06 $74.90 $73.75 $72.60
Child Rate $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80
UnitedHealthcare Medicare Advantage I
Retiree Rate $73.21 $71.43 $69.64 $67.86 $66.07 $64.29 $62.50 $60.71 $58.93 $57.14 $55.36 $53.57 $51.79 $50.00 $48.21 $46.43 $44.64 $42.86 $41.07 $39.29 $37.50
Spouse Rate $74.11 $73.21 $72.32 $71.43 $70.54 $69.64 $68.75 $67.86 $66.96 $66.07 $65.18 $64.29 $63.39 $62.50 $61.61 $60.71 $59.82 $58.93 $58.04 $57.14 $56.25
Child Rate $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00
UnitedHealthcare Medicare Advantage II
Retiree Rate $24.40 $23.81 $23.21 $22.62 $22.02 $21.43 $20.83 $20.24 $19.64 $19.05 $18.45 $17.86 $17.26 $16.67 $16.07 $15.48 $14.88 $14.29 $13.69 $13.10 $12.50
Spouse Rate $24.70 $24.40 $24.11 $23.81 $23.51 $23.21 $22.92 $22.62 $22.32 $22.02 $21.73 $21.43 $21.13 $20.83 $20.54 $20.24 $19.94 $19.64 $19.35 $19.05 $18.75
Child Rate $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00
Revised: August 2021
NMRHCA Age 55+ with Retirement Date on July 31, 2021 or After (Subsidy Level B) Medical Plan Monthly Premium Contributions for January 1, 2022 - December 31, 2022
NMRHCA Enhanced Public Safety or July 1, 2001 - June 30, 2021 Retirement Date* (Subsidy Level A) Medical Plan Monthly Premium Contributions for January 1, 2022 - December 31, 2022
Years of Service 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20+
NON-MEDICARE MEDICAL
Premier PPO (BCBS or Presbyterian)
Retiree Rate
$828.12 $793.61 $759.11 $724.60 $690.10 $655.59 $621.09 $586.58 $552.08 $517.57 $483.07 $448.56 $414.06 $379.55 $345.05 $310.54
Spouse Rate
$900.24 $879.52 $858.79 $838.07 $817.35 $796.63 $775.91 $755.19 $734.46 $713.74 $693.02 $672.30 $651.58 $630.85 $610.13 $589.41
Child Rate
$301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43 $301.43
Value HMO (BCBS or Presbyterian)
Retiree Rate
$646.88 $619.92 $592.97 $566.02 $539.06 $512.11 $485.16 $458.21 $431.25 $404.30 $377.35 $350.39 $323.44 $296.49 $269.53 $242.58
Spouse Rate
$703.17 $686.99 $670.80 $654.62 $638.43 $622.25 $606.06 $589.88 $573.69 $557.50 $541.32 $525.13 $508.95 $492.76 $476.58 $460.39
Child Rate
$235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06 $235.06
MEDICARE MEDICAL
BCBS Medicare Supplemental Plan
Retiree Rate
$457.41 $442.65 $427.90 $413.14 $398.39 $383.63 $368.88 $354.12 $339.37 $324.61 $309.86 $295.10 $280.35 $265.59 $250.84 $236.08
Spouse Rate
$464.78 $457.41 $450.03 $442.65 $435.27 $427.90 $420.52 $413.14 $405.76 $398.39 $391.01 $383.63 $376.25 $368.88 $361.50 $354.12
Child Rate
$472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16 $472.16
BCBS Medicare Advantage I
Retiree Rate
$43.59 $42.19 $40.78 $39.38 $37.97 $36.56 $35.16 $33.75 $32.34 $30.94 $29.53 $28.13 $26.72 $25.31 $23.91 $22.50
Spouse Rate
$44.30 $43.59 $42.89 $42.19 $41.48 $40.78 $40.08 $39.38 $38.67 $37.97 $37.27 $36.56 $35.86 $35.16 $34.45 $33.75
Child Rate
$45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00 $45.00
BCBS Medicare Advantage II
Retiree Rate
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Spouse Rate
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Child Rate
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Humana Medicare Advantage I
Retiree Rate
$85.50 $82.74 $79.99 $77.23 $74.47 $71.71 $68.95 $66.20 $63.44 $60.68 $57.92 $55.16 $52.40 $49.65 $46.89 $44.13
Spouse Rate
$86.88 $85.50 $84.12 $82.74 $81.36 $79.98 $78.60 $77.23 $75.85 $74.47 $73.09 $71.71 $70.33 $68.95 $67.57 $66.19
Child Rate
$88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26 $88.26
Humana Medicare Advantage II
Retiree Rate
$11.18 $10.82 $10.46 $10.10 $9.74 $9.38 $9.02 $8.66 $8.29 $7.93 $7.57 $7.21 $6.85 $6.49 $6.13 $5.77
Spouse Rate
$11.36 $11.18 $11.00 $10.82 $10.64 $10.46 $10.28 $10.10 $9.91 $9.73 $9.55 $9.37 $9.19 $9.01 $8.83 $8.65
Child Rate
$11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54 $11.54
Presbyterian Medicare Advantage I
Retiree Rate
$120.42 $116.53 $112.65 $108.76 $104.88 $100.99 $97.11 $93.23 $89.34 $85.46 $81.57 $77.69 $73.80 $69.92 $66.03 $62.15
Spouse Rate
$122.36 $120.42 $118.47 $116.53 $114.59 $112.65 $110.70 $108.76 $106.82 $104.88 $102.93 $100.99 $99.05 $97.11 $95.16 $93.22
Child Rate
$124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30 $124.30
Presbyterian Medicare Advantage II
Retiree Rate
$93.78 $90.75 $87.73 $84.70 $81.68 $78.65 $75.63 $72.60 $69.58 $66.55 $63.53 $60.50 $57.48 $54.45 $51.43 $48.40
Spouse Rate
$95.29 $93.78 $92.26 $90.75 $89.24 $87.73 $86.21 $84.70 $83.19 $81.68 $80.16 $78.65 $77.14 $75.63 $74.11 $72.60
Child Rate
$96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80 $96.80
UnitedHealthcare Medicare Advantage I
Retiree Rate
$72.66 $70.31 $67.97 $65.63 $63.28 $60.94 $58.59 $56.25 $53.91 $51.56 $49.22 $46.88 $44.53 $42.19 $39.84 $37.50
Spouse Rate
$73.83 $72.66 $71.48 $70.31 $69.14 $67.97 $66.80 $65.63 $64.45 $63.28 $62.11 $60.94 $59.77 $58.59 $57.42 $56.25
Child Rate
$75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00 $75.00
UnitedHealthcare Medicare Advantage II
Retiree Rate
$24.22 $23.44 $22.66 $21.88 $21.09 $20.31 $19.53 $18.75 $17.97 $17.19 $16.41 $15.63 $14.84 $14.06 $13.28 $12.50
Spouse Rate
$24.61 $24.22 $23.83 $23.44 $23.05 $22.66 $22.27 $21.88 $21.48 $21.09 $20.70 $20.31 $19.92 $19.53 $19.14 $18.75
Child Rate
$25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00 $25.00
* This rate sheet also applies to disabled or duty-related disabled members Revised: August 2021
Medical Plan Rate Calculation Instructions
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 or domestic partner, 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/domestic partner is also an NMRHCA-eligible retiree, use the Retiree
Rate that corresponds with your spouse’s/domestic partner’s years of service).
3. If you are also enrolling children, enter rate from Child Rate row multiplied by number of children.
(# of Children: ________ x Child Rate: __________ = Total for Child(ren): _________
4. TOTAL #1, #2, and #3.
$___________ Retiree
+ $___________ Spouse/ Domestic
Partner
+ $___________ Child(ren)
= $___________ Total
Voluntary Coverage Premiums
DENTAL PLAN Monthly Premium
*
:
Effective
J
ul
y
1, 20
20
to
December 31
, 20
2
2
SINGLE TWO-PARTY FAMILY
Delta
Dental
Basic
$18.14 $34.46 for both $ 51.69 for all
Delta Dental
Comprehensive
$37.01 $70.32 for both $105.44 for all
VISION PLAN Monthly Premium*:
Effective July 1, 2020
to
June 30, 2024
Davis Vision
$ 4.62 $ 8.71
for both
$12.83
for all
DEPENDENT
CHILD
LIFE Monthly Premium*
: Effective J
uly
1, 201
9
to
June 30, 2023
The
Standard Insurance
$2,500 - $4.13 for all $5,000 - $7.75 for all $10,000 - $15.00 for all
RETIREE
/SPOUSE
SUPPLEMENTAL LIFE Monthly Premium*: Effective J
ul
y
1, 2019
to
June 30, 2023
The
Standard
$2,000 $4,000 $6,000 $8,000 $10,000 $15,000** $20,000** $40,000** $46,000** $60,000**
Age 35
-
39
$ 0.69 $ 0.88 $ 1.06 $ 1.25 $ 1.44 $ 1.91 $ 2.38 $ 4.26 $ 4.82 $ 6.14
Age 40
-
44
$ 0.80 $ 1.10 $ 1.41 $ 1.71 $ 2.01 $ 2.77 $ 3.52 $ 6.54
$ 7.45
$ 9.56
Age 45
-
49
$ 1.01 $ 1.52 $ 2.02 $ 2.53 $ 3.04 $ 4.31 $ 5.58 $ 10.66 $ 12.18 $ 15.74
Age 50
-
54
$ 1.39 $ 2.27 $ 3.16 $ 4.04 $ 4.93 $ 7.15 $ 9.36 $ 18.22 $ 20.88 $ 27.08
Age 55
-
59
$ 1.97 $ 3.44 $ 4.90 $ 6.37 $ 7.84 $11.51 $15.18 $ 29.86 $ 34.26 $ 44.54
Age 60
-
64
$ 2.29 $ 4.08 $ 5.87 $ 7.66 $ 9.45 $13.93 $18.40 $ 36.30 $ 41.67 $ 54.20
Age
65
-
69
$ 4.17 $ 7.84 $11.52 $15.19 $18.86 $28.04 $37.22 $ 73.94 $ 84.96 $110.66
Age 70 and over
$ 6.13 $11.76 $17.39 $23.02 $28.65 $42.73 $56.80 $113.10 $129.99 $169.40
*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. The life plan rates include a $.50 administration fee.
**Evidence of Insurability Statement required to add or increase life insurance. The Change for Additional Life Insurance form can be found at http://www.nmrhca.org/forms.aspx/.
NMRHCA Pre-55 Retirement Age Medical Plan Monthly Premium Contributions for January 1, 2022 – December 31, 2022
(applicable for members who retired before age 55 and retirement date is July 31, 2021 or after)
NON
-
MEDICARE PLANS
Retiree Rate
Spouse
Rate
Child Rate
Rate Calculation Instructions
Premier PPO (BCBS or Presbyterian)
$862.62 $920.96 $301.43
1. Select a medical plan for the retiree; enter rate
Value Plan (BCBS or Presbyterian)
$673.83 $719.36 $235.06
from Retiree Rate column
MEDICARE PLANS (Not Applicable)
Retiree Rate
Spouse Rate
Child Rate
+
BCBS Medicare Supplemental Plan
N/A
N/A N/A
2. If you are enrolling your spouse
or domestic partner
,
BCBS Medicare Advantage I
N/A N/A N/A select a medical plan for him/her; enter Spouse Rate
BCBS Medicare Advantage II
N/A N/A N/A
+
Humana Medicare Advantage I
N/A N/A N/A
3. If you
are enrolling children, enter rate from Child Rate
Humana Medicare Advantage II
N/A N/A N/A
column multiplied by number of children.
Presbyterian Medicare Advantage II
N/A N/A N/A
Presbyterian Medicare Advantage II
N/A N/A N/A
=
UnitedHealthcare Medicare Advantage I
N/A N/A N/A
4. TOTAL #1, #2, and #3
$
UnitedHealthcare Medicare Advantage II
N/A N/A N/A
DENTAL PLAN Monthly Premium*: July 1, 2020 – December 31, 2022
SINGLE TWO-PARTY FAMILY
Delta Dental Basic
$18.14 $34.46 for both $ 51.69 for all
Delta Dental Comprehensive
$37.01 $70.32 for both $105.44 for all
VISION PLAN Monthly Premium*: Effective July 1, 2020 – June 30, 2024
Davis Vision
$ 4.62
$ 8.71
for both
$12.83
for all
DEPENDENT CHILD LIFE Monthly Premium*: Effective July 1, 2019 – June 30, 2023
The Standard Insurance
$2,500 -
$4.13
for all $5,000 -
$7.75
for all $10,000 -
$15.00
for all
RETIREE/SPOUSE SUPPLEMENTAL LIFE Monthly Premium*: Effective July 1, 2019 – June 30, 2023
The Standard
$2,000 $4,000 $6,000 $8,000 $10,000 $15,000** $20,000** $40,000** $46,000** $60,000**
Age 35-39
$ 0.69 $ 0.88 $ 1.06 $ 1.25 $ 1.44 $ 1.91 $ 2.38 $ 4.26 $ 4.82 $ 6.14
Age 40-44
$ 0.80 $ 1.10 $ 1.41 $ 1.71 $ 2.01 $ 2.77 $ 3.52 $ 6.54
$ 7.45
$ 9.56
Age 45-49
$ 1.01 $ 1.52 $ 2.02 $ 2.53 $ 3.04 $ 4.31 $ 5.58 $ 10.66 $ 12.18 $ 15.74
Age 50-54
$ 1.39 $ 2.27 $ 3.16 $ 4.04 $ 4.93 $ 7.15 $ 9.36 $ 18.22 $ 20.88 $ 27.08
Age 55-59
$ 1.97 $ 3.44 $ 4.90 $ 6.37 $ 7.84 $11.51 $15.18 $ 29.86 $ 34.26 $ 44.54
Age 60-64
$ 2.29 $ 4.08 $ 5.87 $ 7.66 $ 9.45 $13.93 $18.40 $ 36.30 $ 41.67 $ 54.20
Age 65-69
$ 4.17 $ 7.84 $11.52 $15.19 $18.86 $28.04 $37.22 $ 73.94 $ 84.96 $110.66
Age 70 and over
$ 6.13 $11.76 $17.39 $23.02 $28.65 $42.73 $56.80 $113.10 $129.99 $169.40
* NOTE: This is optional coverage, and the entire cost is paid by you. Cost of insurance for all coverage’s 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. The life plan rates include a $.50 administration fee.
**Evidence of Insurability Statement required to add or increase life insurance. The Change for Additional Life Insurance form can be found at http://www.nmrhca.org/forms.aspx/.