Official MHBP plan documents
Plan brochures, forms and documents to help you with your benefits.
Click documents to view / download
Member plan brochures
Retiree documents
- 2024 Retiree plan brochure PDF - opens in a new window
- 2024 Medicare – Annual Notice of Change PDF - opens in a new window
- 2024 Medicare – Evidence of Coverage PDF - opens in a new window
- 2024 Medicare – Plan Document Notice PDF - opens in a new window
- 2024 Medicare – Schedule of Cost Sharing PDF - opens in a new window
- 2024 Medicare – Summary of Benefits PDF - opens in a new window
- 2023 Retiree plan brochure PDF - opens in a new window
- 2023 Medicare – Evidence of Coverage PDF - opens in a new window
- 2023 Medicare – Plan Document Notice PDF - opens in a new window
- 2023 Medicare – Schedule of Cost Sharing PDF - opens in a new window
- 2023 Medicare – Summary of Benefits PDF - opens in a new window
Claim forms
- CVS/Caremark prescription reimbursement claim form PDF - opens in a new window
- Dental claim form (MHBP Dental plan only) PDF - opens in a new window
- Medical claim form PDF - opens in a new window
- Overseas Medical claim form PDF - opens in a new window
- Wellness Incentive claim form PDF - opens in a new window
Member forms
- Coordination of Benefits form PDF - opens in a new window
- CVS/Caremark prescription mail service order form PDF - opens in a new window
- Consumer Option HRA Reimbursement request PDF - opens in a new window
- Consumer Option HSA Transfer form PDF - opens in a new window
- Consumer Option HSA Excess contribution form PDF - opens in a new window
- Health Savings Account (HSA) Custodial agreement PDF - opens in a new window
- Health Savings Account (HSA) Fee schedule PDF - opens in a new window
- MHBP Brand Exception form PDF - opens in a new window
- Utah Network selection form PDF - opens in a new window
- Authorization for release of protected health information (PHI) PDF - opens in a new window
- Contraceptive management exception form PDF - opens in a new window
- 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.
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