City of Manchester, NH Official Website

Health Insurance Information and Forms

Below are quick links to get you to the correct section that will have your health insurance rate information and forms. Click on the link that coincides with your Affiliation:

Click on the links below for more information on the following:

Summary of Benefits and Coverage for all Health Plans

The purpose of the Summary of Benefits and Coverage (SBC) is to provide individuals with standard information so they can compare medical plans as they make decisions about which plans to choose. 

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Rate Charts and Enrollment Forms


AFSCME and School Nurses


Library Teamsters


Non Affiliated


USWA Water Union

Welfare Teamsters

Health Insurance Opt-Out Incentive Program Rules & Forms

This program offers a cash incentive to eligible City of Manchester employees who waive their right to enroll in the City's Health Insurance plan.

See below for rules and form:

You must re-apply for the incentive each fiscal year! If you applied and received the incentive last year, you will not automatically get it again this fiscal year - you must re-apply for it.

If you are currently on the City's health insurance, you must also complete the Health Insurance Enrollment/Change form to cancel your health Insurance. 

The Incentive is considered ordinary income and therefore subject to Federal, State, Social Security, and Medicare taxes and City and State Retirement deductions.

Additional Health Benefit Information and Forms

Away from Home Care Program

  • Away From Home Care Brochure
    As a Blue Cross Blue Shield Plan HMO member, Away from Home Care provides healthcare coverage while you are away from your Home, such as a child going to college out of state. Read this brochure for an overview of the program.
  • Away From Home Care Participating States Booklet
    This booklet shows the states in the US that participate in Anthem's Away From Home Care program. There are some areas within the participating states that do not offer the program so call Anthem to verify the area you are going to is a participant.

Other Forms

  • Individual Authorization Form
    Complete this form if you want to allow someone else to be able to make inquires on your behalf regarding your Anthem Health care concerns and claims.
  • IngenioRX Mail Order Form
    Use this form to request prescriptions by mail. The easiest and quickest method is to have your doctor fax it in for you. This information is on the form.
  • IngenioRX Reimbursement Form
    Use this form if you paid for a prescription out of pocket and need to request reimbursement.
  • Handicapped Form
    Handicapped Request Form.
  • Vision & Medical Reimbursement Form
    Use this form to request reimbursement for Vision and Medical expenses paid out of pocket.

Utilization Reports 

These reports were completed for the City of Manchester by Anthem Blue Cross & Blue Shield. They are in-depth analysis of the medical claims for the City of Manchester.

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