Benefit Information - Health and Dental
SUMMARY OF BENEFITS
|
HEALTH AND DENTAL RATE SHEETS
MEDICAL - TOWN NON-UNION AND AFSCME
HealthTrust 25 Triangle Park Drive Concord, NH 03301 Toll free 800-527-5001
PO Box 617 Concord, NH 03302-0617 | Type of Plan / Links
About Health Trust (30 min video) |
| APPLICATION | Application - Use this application if signing up for HealthTrust Medical AND Dental
DENTAL ONLY Application - Use this application if signing up for DENTAL ONLY
|
Medical Plan AB15/40 (1K/3K deductible) Plan Documents For ACTIVE and COBRA PARTICIPANTS |
ACCESS BLUE NEW ENGLAND - AB 15/40 IPDED(01L)-R10/25/40M10/40/70/5K(L) Group Number 362223M010 (new number for Active/COBRA)
2024 |
Medical Plan ABSOS (3K/9K deductible) Plan Documents For ACTIVE and COBRA PARTICIPANTS |
ACCESS BLUE NEW ENGLAND ABSOS 25/50/3KDED(01L)-R10/25/40M10/40/70/5K(L) Group Number 362223M014 (new number for Active/COBRA)
2024 |
| FORMS |
LifeResources - EAP - Employee Assistance Program To contact the LifeResources - Employee Assistance Program call 800.759.8122.
Anthem Participating Primary Care Provider List 2020
Program Materials
Vision - Anthem Vision Discounts
WAIVER Form - Health and Dental - Town and AFSCME
UPDATED EFF 11.28.2023 |
RETIREES
RETIREES - 65 AND UNDER - PLAN INFORMATION / PLAN DOCUMENTS
Retiree Coverage - UNDER 65 WITHIN NEW ENGLAND AREA Early Retiree Benefit Packet 2023
UNDER 65 OUTSIDE NEW ENGLAND AREA |
AB15/40 RETIREE UNDER 65 WITHIN NEW ENGLAND AREA Group Number 362223M011 (new number for Under 65 Retirees)
2024
2023 Summary of Benefits and Coverage
SOS RETIREE UNDER 65 WITHIN NEW ENGLAND AREA Group Number 362223M015 (new number for Under 65 Retirees)
2023 Summary of Benefits and Coverage ___________________________________________________________________________________
RETIREE UNDER 65 and OUTSIDE the NEW ENGLAND AREA 2023 LUMENOS (SBC) Summary of Benefits and Coverage LUMENOS Subscriber Certificate __________________________________________________________________________________ | ||||||||||||||||||||||||||||||||||||||||||||||||
RETIREES - 65 AND OVER - PLAN INFORMATION
Retiree Coverage - Over 65 |
2023 MEDICOMP THREE - MC3(01L)-R10/25/40M10/40/70(LCY) (includes prescriptions)
2023 MEDICOMP THREE - MCNRX(01L) (Medical only. Prescription is chosen by retiree from the marketplace) NO Prescription ___________________________________________________________________________________ | ||||||||||||||||||||||||||||||||||||||||||||||||
Retiree FORMS | Retiree Medical and/or Dental Application and Change Form NHRS Annuity Deduction | ||||||||||||||||||||||||||||||||||||||||||||||||
| Retiree Videos | Retiree Information video | ||||||||||||||||||||||||||||||||||||||||||||||||
| HealthTrust Submission Timeframes | Submission Timeframes | ||||||||||||||||||||||||||||||||||||||||||||||||
| Other | Notice of Privacy Practices | ||||||||||||||||||||||||||||||||||||||||||||||||
FLEXIBLE SPENDING ACCOUNT (FSA)
FSA updated 11.30.23 | Flexible Spending Account FSA Enrollment Form (2024) - fillable
FSA Brochure Rev 2023 FSA Claim Form Rev 3.2023 FSA Election Worksheet Rev 2.14.23 FSA Healthcare Eligible Expenses Rev 4.2023
|
| Prior Plan Docs | FSA Plan Document (2021) |
Grace Period - Last day of the Grace Period: Fifteenth day of the 3rd month following end of the play year. (3/15/xx) Claims submitted from 1/1 - 3/15 for a prior year should be submitted manually (fax, scan, etc.). |
DENTAL - ALL EMPLOYEES
Delta Dental One Delta Drive PO Box 2002 Concord, NH 03302 Toll free 800-537-1715 | Type of Plan |
| Application | DENTAL ONLY Application - If Teamster or only taking Dental insurance through the Town (if opting out of the Town's Health Insurance) |
| Dental Plans | Outline of Benefits - High Option 1O FLX - 3116-5486 Outline of Benefits - Low Option 4 FLX - 3116 - 5490 |
| Plan Documents | |
| Vision | Delta Dental EyeMed Discount - Vision Care Discount |
| Waiver | See "Waiver Form - Health and Dental - Town and AFSCME" |
MEDICAL - TEAMSTER'S
CONTRACT SURRENDERED NH LOCAL #633 EFFECTIVE 9/20/23
ALLEGIANT CARE INSURANCE EXPIRES 10/31/23
| Attachment | Size |
|---|---|
 FSA Enrollment Form (2024) | 1.25 MB |
| FSA Benefit Advantage List of Eligible Expenses (2024) | 82.11 KB |
| 2024 FSA Signed Agreement | 512.35 KB |
| 2024 FSA Brochure | 1.44 MB |
| FSA Election Worksheet Rev 2.14.2023 | 73.66 KB |
| FSA Claim Form Rev 3.2023 | 243.76 KB |
| Summary of Benefits - Non Union Employees | 279.55 KB |