Cigna Medicare Access Forms

Effective 1/1/2012 all retirees over 65 will be on the Anthem Medicare Preferred (PPO) plan. This is a Medicare Advantage Plan. Please ensure that you give your providers your Anthem Card only, you do not need to give them your Medicare Card.

Below you will find information and guides on the Anthem plan. Just click on the links highlighted in blue:

MEDICAL PLAN INFORMATION AND BROCHURE:

MEDICARE BOOKLETS AND INFORMATION:

2012 Medicare and You Handbook

HEALTH CARE REFORM UPDATES FROM MEDICARE:

Medicare and the New Health Care Law (entered 10/4/2010)
Closing the Prescription Drug Coverage Gap (entered 10/4/2010)

last changed 1/20/2012

Over 65 Plan Forms & Information

Title	Modified Date	Size		Description
7/1/2011-6/30/2012 Health & Dental Rate Schedule	1/23/2012	8.64 KB	Download	Insurance Rate Chart for FY2012. Anthem Medicare Preferred rates guaranteed until 12/31/2012.
Delta Dental Outline of Benefits	8/2/2010	13.82 KB	Download	Delta Dental Outline of Benefits
Delta Dental Plan Booklet	8/2/2010	Unknown	Download	Detailed booklet explaining your dental coverage; what is covered and at what percentage it is covered, etc
Delta Dental Provider Directory	1/20/2012	895.00 KB	Download	A directory of participating Delta Dental Dentists
Dental Enrollment/Change Form	8/11/2011	437.99 KB	Download	This form is to terminate, enroll in or make changes to your dental insurance
Health Insurance Cancellation Form	6/8/2010	92.50 KB	Download	If you are cancelling your health insurance you must fill out this form along with the Health Insurance Enrollment/Change Form
Health Insurance Enrollment/Change Form	1/20/2012	222.62 KB	Download	This form is to terminate, enroll in or make changes to your health insurance. If you are cancelling your health insurance you must also fill out the Health Insurance Cancellation Form
Health Insurance Individual Authorization Form	1/20/2012	49.62 KB	Download	This form is to enable another individual to call on your behalf to Anthem Blue Cross Blue Shield
Mail Order Prescription Drug Form	1/20/2012	44.90 KB	Download	To order a new prescriptiion from Expess Scripts mail order pharmacy complete this form
NH Retirement Annuity Deduction Authorization Form	4/20/2011	Unknown	Download	Fire & Police retirees, you must complete this form if you are making any changes that affect your insurance premiums
NHRS Retiree Insurance Rate Chart	1/20/2012	7.70 KB	Download	Fire & Police retirees FY2011 Rate Schedule including NHRS Subsidy Amounts

Contacts

Benefits Coordinators
Jane LaPerle/Susan Figg
City of Manchester
HR Dept./Benefits
One City Hall Plaza
Manchester, NH 03101
Phone (603) 624-6543
Fax (603) 628-6065
Email Address:
benefitscoordinator@manchesternh.gov

Contributory Retirement System
Phone (603) 624-6506
Fax (603) 624-6342
Email Address:
gfleury@manchesterretirement.org
Web Site: www.manchesterretirement.org

New Hampshire Retirement System
Phone (603) 410-3500
Toll Free (877) 600-0158
Fax (603) 410-3501
Email Address: info@nhrs.org
Web site: www.nhrs.org

MEDICAL PLAN INFO:
Anthem Medicare Preferred (PPO) Group Plan

Anthem Blue Cross Blue Shield
Customer Service: (877) 411-1640
TTY users call: (877) 247-1657
Fax: (888) 458-1406
Web site: www.anthem.com/medicare

Anthem Medicare Preferred (PPO)
P.O. Box 110
Fond du Lac, WI 54936

PHARMACY HOME DELIVERY INFO:
Express Scripts Pharmacy
Customer Service: (888) 565-8361
Hearing-impaired call: (800) 221-6915

Mail new prescription order forms to:
Express Scripts
Home Delivery Service
P.O. Box 66785
Saint Louis, MO 63166-6785

DENTAL INFO:
Northeast Delta Dental Plan
One Delta Drive
P.O. Box 2002
Concord, NH 03302-2002
Customer Service/Lost Card
Phone (603) 223-1234
Claim Issues Customer Service
Phone (800) 832-5700
Web site: www.nedelta.com

MEDICARE INFO:
Customer Service: (800) 633-4227
TTY users call: (877) 486-2048
Hours: 24 hrs a day/7 days a week
Web site: www.medicare.gov

SOCIAL SECURITY INFO:
Customer Service: (800) 772-1213
TTY users call: (800) 325-0778
Hours: 7:00 am to 7:00 pm Mon-Fri
Web site: www.ssa.gov

last changed 1/20/2012