Health & Dental Insurance
Health & Dental Contributory Retirement Rate Chart Insurance Rate Chart for Contributory Retirees. This does not include the Contributory Retirement Subsidy Amounts.
Health & Dental New Hampshire Retirement Rate Schedule Insurance Rate Chart for New Hampshire State Retirees (Police & Fire) including the NH Subsidy Amounts. United American Supplement Plan F Summary of Benefits United American Supplemental Plan G Summary of Benefits Summary of your Medicare (Part A) Hospital and (Part B ) Medical Services benefits and United American benefit coverage. Plan G is fonly or retirees turning 65 on 1/1/20 or after and who live in FL, MN or WA. Express Scripts (Part D) Overview of Benefits Summary of Benefits for your prescription drug coverage.
Prescription Plan Express Scripts Evidence of Coverage Evidence of Coverage for your Medicare Prescription Drug Coverage with Express Scripts.
Express Scripts Prescription Formulary This booklet covers information about the drugs that United American Covers. Delta Dental Outline of Coverage Delta Dental Outline of Benefits & Dental Outline of Coverage.
Delta Dental Plan Booklet Detailed booklet explaining your dental coverage; what is covered and at what percentage it is covered, etc.
Delta Dental Vision Discount Program Free Vision Discount Program offered by Delta Dental. Great savings of up to 35%.
Dental Enrollment/Change Form This form is to terminate, enroll in or make changes to your dental insurance.
United American Enrollment Form This form is to enroll into United American's Medicare Supplement F plan. NH Retirement Annuity Deduction Authorization Form Fire & Police retirees, you must complete this form if you are making any changes that affect your health and/or dental insurance premiums.
Health Insurance Cancelation Form Read/sign this form and complete the Health Insurance Disenrollment form below if you wish to cancel your health insurance. Health Insurance Disenrollment Form Complete this form and read/sign the Health Insurance Cancelation form above if you wish to cancel your health insurance. Prescription Home Delivery Form If you want to do mail order/home delivery for your prescriptions with Express Scripts click here.
www.Express-Scripts.com or call 1-888-345-2560
This website and its contents are a service of the City of Manchester, NH