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Health Insurance Information and Forms


Click on the links for information, enrollment forms and current rates for City of Manchester Health Insurance Plans:

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


This following form must be read & signed by all employees enrolling in the HDHP with an HSA Account.

​The following form must be complete if you want to contribute to your HSA through payroll deductions.

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 Notices, Forms and Information

  • 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.
  • Quit Smoking Brochure
    ​Under health care reform, you can get certain FDA-approved prescription drugs and many Over the Counter products and nicotine replacement products at no cost to you!
  • 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.
  • Generic Select Brochure
    The Generic Select program lets you try a generic option on Anthem's list and get that first prescription at no cost.
  • Anthem's Special Offers
    Learn about the many discounts on products and services offered by Anthem. 
  • Anthem's 24/7 Nurse Line
    The 24/7 Nurse Line puts you in touch with a registered nurse who can help you decide how to handle a medical issue. Call 800-544-1901.
  • Anthem 360 Health Program Brochure
    Information on Anthem's Health Programs and Discounts offered to the City of Manchester employees on the Anthem plan.

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.

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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