MHBP Official Plan Brochures

Below is a listing of plan forms, brochures and documents to help you manage and understand your benefits.

Member Forms & Documents
Title Description Download
Plan Brochure 2024 MHBP Plans Overview Brochure PDF
Plan Brochure 2024 OPM Brochure – Standard Option and Value Plan PDF
Plan Brochure 2024 OPM Brochure – Consumer Option Plan PDF
SBC – 2024 Standard Option 2024 Summary of Benefits and Coverage, Standard Option PDF
SBC – 2024 Value Plan 2024 Summary of Benefits and Coverage, Value Plan PDF
SBC – 2024 Consumer Option 2024 Summary of Benefits and Coverage, Consumer Option PDF
Plan Brochure 2024 Medicare Plan Brochure PDF
Plan Brochure 2024 Aetna Medicare Advantage Plan for MHBP Summary of Benefits PDF
Plan Brochure 2024 Annual Notice of Change PDF
Plan Brochure 2024 Evidence of Coverage PDF
Plan Brochure 2024 Plan Document Notice PDF
Plan Brochure 2024 Schedule of Cost Sharing PDF
Prescription Drug List 2024 5 Tier Comprehensive Plus Formulary PDF
Prescription Drug List 2024 Prior Authorization Details PDF
Prescription Drug List 2024 Prescription Drug Guide/Formulary PDF
Prescription Drug List 2024 Step Therapy Detail PDF
Prescription Drug List 2024 Formulary Changes PDF
Prescription Drug List 2024 Non-Part D Rider PDF
Prescription Drug List 2024 Essential Health Supplemental Benefit PDF
Plan Form PDP Disenrollment form PDF
Plan Brochure 2023 MHBP Plans Overview Brochure PDF
Plan Brochure 2023 OPM Brochure – Standard Option and Value Plan PDF
Plan Brochure 2023 OPM Brochure – Consumer Option Plan  PDF
SBC – 2023 Standard Option 2023 Summary of Benefits and Coverage,  Standard Option PDF
SBC – 2023 Value Plan 2023 Summary of Benefits and Coverage, Value Plan PDF
SBC – 2023 Consumer Option 2023 Summary of Benefits and Coverage, Consumer Option PDF
Plan Brochure 2023 Medicare Plan Brochure PDF
Plan Brochure 2023 Medicare – 2023 Schedule of Cost Sharing – Medicare Advantage PDF
Plan Brochure 2023 Medicare – 2023 Evidence of Coverage – Medicare Advantage PDF
Plan Brochure 2023 Medicare Summary of Benefits Guide PDF
Member Guide Know Where to Go PDF
Member Guide Making the Most out of MHBP PDF
Prescription Drug Form Contraceptive Management Exception Form

  • Learn more about contraception resources at OPM’s webpage.
  • Please contact OPM if you have difficulty accessing contraceptive coverage or other reproductive health by contacting contraception@opm.gov.
  • For additional information members can learn more about their reproductive rights at HHS website.
PDF
Prescription Drug List Prescription Drug Guide/Formulary PDF
Prescription Drug List Advanced Control Specialty Formulary PDF
Prescription Drug List Formulary Exclusion Drug List PDF
Member Form Prescription Drug Brand Exception Form PDF
Claim Form Medical Claim Form PDF
Claim Form Prescription Reimbursement Claim Form PDF
Claim Form International Medical claim form PDF
Claim Form Dental Claim Form (MHBP Dental Plan only) PDF
Claim Form Wellness Incentive Claim Form PDF
Claim Form Prescription, Mail Order Caremark Mail Order Service Claim Form PDF
Member Form Coordination of Benefits Form PDF
Member Form Consumer Option HRA Reimbursement Request PDF
Member Form Consumer Option HSA Transfer Form PDF
Member Form Consumer Option HSA Excess Contribution Form PDF
Member Form Health Savings Account (HSA) Custodial Agreement PDF
Member Form Health Savings Account (HSA) Fee Schedule PDF
Member Form Utah Network Selection Form PDF
Privacy Notices Privacy notice PDF
Privacy Notices Privacy Notice – Spanish PDF
Member Form Authorization for Release of Protected Health Information (PHI) PDF
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

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