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 |
|---|---|---|
| Plan Brochure | 2023 MHBP Plans Overview Brochure | |
| Plan Brochure | OPM Brochure – Standard Option and Value Plan 2023 | |
| Plan Brochure | OPM Brochure – Consumer Option Plan 2023 | |
| SBC – 2023 Standard Option | Summary of Benefits and Coverage, 2023 Standard Option | |
| SBC – 2023 Value Plan | Summary of Benefits and Coverage, 2023 Value Plan | |
| SBC – 2023 Consumer Option | Summary of Benefits and Coverage, 2023 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 | |
| Plan Brochure | 2022 MHBP Plans Overview Brochure | |
| Plan Brochure | OPM Brochure – Standard Option and Value Plan 2022 | |
| Plan Brochure | OPM Brochure – Consumer Option Plan 2022 | |
| 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 |
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