Summaries of Benefits and Coverage

Administrative Support Staff (AFSCME Local 1801)

• Access Blue (HMO) $10 Copay – AB10; R$X10/20/45
• Access Blue (HMO) $15 Copay w/Deductible – AB15IPDED; RX10/20/45
• Lumenos 2500 (HSA-Qualified High-Deductible Plan) – L2500
• Delta Dental Option 1

Firefighters / Fire Officers (IAFF Local 4392)

• Access Blue (HMO) $10 Copay – AB10; RX10/20/45
• Access Blue (HMO) $15 Copay w/Deductible – AB15IPDED; RX10/20/45
• BlueChoice (POS) $5 Copay – BC3T5RDR; RX10/20/45+ (No longer available after June 30, 2025.)
• Lumenos 2500 (HSA-Qualified High-Deductible Plan) – L2500
• Delta Dental Option 1S

Police Patrolman's Association (NEPBA Local 38)

• Access Blue (HMO) $10 Copay – AB10; RX10/20/45
• Access Blue (HMO) $15 Copay w/Deductible – AB15IPDED; RX10/20/45
• BlueChoice (POS) $5 Copay – BC3T5RDR; RX10/20/45+ (No longer available after June 30, 2025.)
• Lumenos 2500 (HSA-Qualified High-Deductible Plan) – L2500
• Delta Dental Option 1

Police Supervisors (SEIU Local 1984)

• Access Blue (HMO) $10 Copay – AB10; RX10/20/45
• Access Blue (HMO) $15 Copay w/Deductible – AB15IPDED; RX10/20/45
• Lumenos 2500 (HSA-Qualified High-Deductible Plan) – L2500
• Delta Dental Option 1

Professional, Administrative and Technical Employees (SEIU Local 1984)

• Access Blue (HMO) $10 Copay – AB10; RX10/20/45
• Access Blue (HMO) $15 Copay w/Deductible – AB15IPDED; RX10/20/45
• Lumenos 2500 (HSA-Qualified High-Deductible Plan) – L2500
• Delta Dental Option 1

Public Works (Teamsters Local 633)

• CIGNA Open Access Plus

Non-Represented Employees

• Access Blue (HMO) $10 Copay - AB10; RX10/20/45
• Access Blue (HMO) $15 Copay w/Deductible - AB15IPDED; RX10/20/45
• BlueChoice POS $5 Copay - BC3T5RDR; RX10/20/45+ (No longer available after June 30, 2025.)
• Lumenos 2500 (HSA-Qualified High-Deductible Plan) – L2500
• Delta Dental Option 1

Retiree Medicare Supplement

• Medicomp Three with Prescription Coverage - MC3; RX10/20/45
• Medicomp Three without Prescription Coverage - MCNRX

Derry Public Library

• Access Blue (HMO) $20 Copay - AB20; RX10/20/45
• Access Blue (Site of Service) $20/40 Copay - ABSOS 20/40/IKDED; RX10/20/45
• Delta Dental Option 1

Taylor Library

• Access Blue High Deductible
• Delta Dental Option 3A