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 2022 MHBP Plans Overview Brochure PDF
Plan Brochure OPM Brochure – Standard Option and Value Plan 2022 PDF
Plan Brochure OPM Brochure – Consumer Option Plan 2022 PDF
SBC – 2022 Standard Option Summary of Benefits and Coverage, 2022 Standard Option PDF
SBC – 2022 Value Plan Summary of Benefits and Coverage, 2022 Value Plan PDF
SBC – 2022 Consumer Option Summary of Benefits and Coverage, 2022 Consumer Option PDF
2022 Medicare  Summary of Benefits Guide – 2022 Aetna Medicare Advantage for MHBP Standard Option members PDF
2022 Medicare  2022 MHBP Medicare Brochure PDF
2022 Medicare  Medicare Rewards Program – Medicare Advantage PDF
Plan Brochure OPM Brochure – Standard Option and Value Plan 2021 PDF
Plan Brochure OPM Brochure – Consumer Option Plan 2021 PDF
Member Guide Know Where to Go PDF
Member Guide Making the Most out of MHBP PDF
Prescription Drug Form Contraceptive Management Exception Form 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
Prescription Drug List Prior Authorization 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

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