MHBP Official Plan Brochures
Below is a listing of plan forms, brochures and documents to help you manage and understand your benefits.
Title | Description | Download |
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Plan Brochure | 2024 MHBP Plans Overview Brochure | |
Plan Brochure | 2024 OPM Brochure – Standard Option and Value Plan | |
Plan Brochure | 2024 OPM Brochure – Consumer Option Plan | |
SBC – 2024 Standard Option | 2024 Summary of Benefits and Coverage, Standard Option | |
SBC – 2024 Value Plan | 2024 Summary of Benefits and Coverage, Value Plan | |
SBC – 2024 Consumer Option | 2024 Summary of Benefits and Coverage, Consumer Option | |
Plan Brochure | 2024 Medicare Plan Brochure | |
Plan Brochure | 2024 Aetna Medicare Advantage Plan for MHBP Summary of Benefits | |
Plan Brochure | 2024 Annual Notice of Change | |
Plan Brochure | 2024 Evidence of Coverage | |
Plan Brochure | 2024 Plan Document Notice | |
Plan Brochure | 2024 Schedule of Cost Sharing | |
Prescription Drug List | 2024 5 Tier Comprehensive Plus Formulary | |
Prescription Drug List | 2024 Prior Authorization Details | |
Prescription Drug List | 2024 Prescription Drug Guide/Formulary | |
Prescription Drug List | 2024 Step Therapy Detail | |
Prescription Drug List | 2024 Formulary Changes | |
Prescription Drug List | 2024 Non-Part D Rider | |
Prescription Drug List | 2024 Essential Health Supplemental Benefit | |
Plan Form | PDP Disenrollment form | |
Plan Brochure | 2023 MHBP Plans Overview Brochure | |
Plan Brochure | 2023 OPM Brochure – Standard Option and Value Plan | |
Plan Brochure | 2023 OPM Brochure – Consumer Option Plan | |
SBC – 2023 Standard Option | 2023 Summary of Benefits and Coverage, Standard Option | |
SBC – 2023 Value Plan | 2023 Summary of Benefits and Coverage, Value Plan | |
SBC – 2023 Consumer Option | 2023 Summary of Benefits and Coverage, Consumer Option | |
Plan Brochure | 2023 Medicare Plan Brochure | |
Plan Brochure | 2023 Medicare – 2023 Schedule of Cost Sharing – Medicare Advantage | |
Plan Brochure | 2023 Medicare – 2023 Evidence of Coverage – Medicare Advantage | |
Plan Brochure | 2023 Medicare Summary of Benefits Guide | |
Member Guide | Know Where to Go | |
Member Guide | Making the Most out of MHBP | |
Prescription Drug Form | Contraceptive Management Exception Form
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Prescription Drug List | Prescription Drug Guide/Formulary | |
Prescription Drug List | Advanced Control Specialty Formulary | |
Prescription Drug List | Formulary Exclusion Drug List | |
Member Form | Prescription Drug Brand Exception Form | |
Claim Form | Medical Claim Form | |
Claim Form | Prescription Reimbursement Claim Form | |
Claim Form | International Medical claim form | |
Claim Form | Dental Claim Form (MHBP Dental Plan only) | |
Claim Form | Wellness Incentive Claim Form | |
Claim Form | Prescription, Mail Order Caremark Mail Order Service Claim Form | |
Member Form | Coordination of Benefits Form | |
Member Form | Consumer Option HRA Reimbursement Request | |
Member Form | Consumer Option HSA Transfer Form | |
Member Form | Consumer Option HSA Excess Contribution Form | |
Member Form | Health Savings Account (HSA) Custodial Agreement | |
Member Form | Health Savings Account (HSA) Fee Schedule | |
Member Form | Utah Network Selection Form | |
Privacy Notices | Privacy notice | |
Privacy Notices | Privacy Notice – Spanish | |
Member Form | Authorization for Release of Protected Health Information (PHI) | |
Aetna Clinical Policy Bulletins (CPBs) | These documents explain how we make coverage decisions for services covered under our official Plan brochure. The medical, pharmacy and behavioral health CPBs are based on objective, credible sources, such as the scientific literature, guidelines, consensus statements and expert opinions. | LINK |
Have Questions? Call 1-800-410-7778 (TTY: 711)
24 hours a day, 7 days a week, except certain holidays