2021 NEW RETIREE (UNDER 65) INSURANCE …
2023 NEW RETIREE INSURANCE BENEFITS ELECTION FORM For Retirees Under Age 65
This form must be received by the Benefits Administration Unit no later than thirty (30) days following your retirement date, otherwise you forfeit Retiree Group coverage.
Name: _______________________________________ Emp. ID: ______________ Date of Retirement: ___________________ Address: _____________________________________ City, State, & Zip Code: _______________________________________ Date of Birth: ______________ Phone: _______________ E-Mail Address: ___________________________________________
MEDICAL COVERAGE
If yes, please select () one of the following options:
Monthly Rates
SELECT
AvMed POS
DECLINE
AvMed High Opt HMO
Retiree Under 65
$1,555.40
$ 692.14
Retiree Under 65 & Spouse/Domestic Partner Under 65
$2,996.95
$1,521.20
Retiree Under 65 & Child(ren)
$2,848.85
$1,403.35
Retiree Under 65 & Spouse/Domestic Partner Under 65, plus Child(ren)
$3,767.54
$1,876.29
Retiree Under 65 & Spouse/Domestic Partner Over 65 and/or Medicare Eligible on AvMed High With RX**
$2,368.27
$1,505.01
Retiree Under 65 & Spouse/Domestic Partner Over 65 and/or Medicare Eligible on AvMed High W/O RX **
$1,045.47
Retiree Under 65 & Children, Spouse/Domestic Partner Over 65 and/or Medicare Eligible on AvMed High With RX**
$3,025.01
$1,997.02
Retiree Under 65 & Children, Spouse/Domestic Partner Over 65 and/or Medicare Eligible on AvMed High W/O RX**
$1,537.48
*AvMed Plans not available outside Miami-Dade, Broward & Palm Beach Counties - **Must be enrolled in Medicare Parts A and B to be eligible for any of the AvMed over 65 plans
AvMed MDC Select
Network HMO* $ 629.35 $1,389.53 $1,281.33 $1,715.67 $1,442.22
$1,899.19
AvMed MDC Jackson First
HMO*
$ 504.29
$1,127.04
$1,038.21
$1,395.55
DENTAL COVERAGE
SELECT
*Dental Rates for 2023 not finalized, please refer to for updated rates
*
Monthly Rates
Retiree Only
Retiree & one dependent
Retiree & dependents
DECLINE If yes, please select () one of the following options:
Delta Dental PPOSM
Standard
Enriched
$ 29.03
$ 40.87
$ 57.44
$ 80.80
$ 92.58
$ 130.30
DeltaCare? DHMO
Standard
Enriched
$ 10.08
$ 11.29
$ 16.65
$ 18.72
$ 25.48
$ 29.77
VISION COVERAGE
If yes, please select () one of the following options:
Monthly Rates for:
Retiree Only Retiree & one dependent Retiree & dependents
SELECT
DECLINE
Humana Vision Program
Standard
Enriched
$7.36
$9.08
$14.72
$18.15
$26.44
$33.38
If medical, dental and/or vision coverage for dependent(s) is selected, please provide the information below.
Name
Relationship**
SSN
DOB
M/F
**SP- Spouse, CH-Child, DP-Domestic Partner, DPCH- Child of Domestic Partner
Indicate Coverage Selected
Medical
Dental
Vision
Medical
Dental
Vision
Medical
Dental
Vision
LIFE INSURANCE COVERAGE
SELECT
DECLINE
The value of the Miami-Dade County Retiree Group Life Insurance Policy is one-time your base annual salary at the time of retirement. The 2022 rate is 17.6 cents per thousand dollars per month. To update your life insurance beneficiary designation, visit .
_______________ I am aware that it is my responsibility to read and understand the contents of the Retiree Insurance Benefits Handbook
Initials
available at .
Signature
FOR OFFICE USE ONLY
Status:
Ret. Kind:
Longevity: FRS ______ County ________
Date
Ret. Type: Other Remarks: ____________________
Please sign, date, and mail or fax this form to: Miami-Dade County - Human Resources Benefits Administration Division 111 NW 1st Street, Suite 2324 Miami, FL 33128-1979 Fax: 305-375-1633 or 305-375-1368
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