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Official Plan Documents

MHBP Official Plan Brochures

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

Forms & Documents Library
Title Description Download
Brand Exception Prescription Drug Brand Exception Form PDF
Claim Form Medical Claim Form PDF
Claim Form Prescription, Retail Pharmacy Prescription Drug Claim form for prescriptions from a retail pharmacy PDF
Claim Form Prescription, Mail Order Caremark Mail Order Service Claim Form PDF
Claim Form International Medical claim form for services received outside the United States PDF
Claim Form Dental Claim Form (MHBP Dental Plan only) PDF
Coordination of Benefits (COB) Use this form to update us with information about other health insurance coverage you may have PDF
Plan Brochure OPM Brochure - Standard Option and Value Plan 2018 PDF
Plan Brochure OPM Brochure - Consumer Option 2018 PDF
Plan Brochure OPM Brochure - Standard Option and Value Plan 2017 PDF
Plan Brochure OPM Brochure - Consumer Option 2017 PDF
Plan Handbook Consumer Option Handbook 2017 PDF
Prescription Drug List Medical Necessity Drug Listing 2017 PDF
Prescription Drug List Specialty Prescription Drug Listing PDF
Prescription Drug List Prior Authorization Drug Listing PDF
Prescription Drug List Prescription Drug Guide/Formulary PDF
Prescription Drug List Advanced Control Specialty Formulary PDF
Provider Nomination Provider Nomination Form PDF
HRA Direct Deposit HRA Direct Deposit Form PDF
HRA Reimbursement HRA Reimbursement Form PDF
HSA Authorization HSA Authorization/Enrollment Form PDF
SBC - 2018 Consumer Option Summary of Benefits and Coverage, 2018 Consumer Option PDF
SBC - 2018 Standard Option Summary of Benefits and Coverage, 2018 Standard Option PDF
SBC - 2018 Value Plan Summary of Benefits and Coverage, 2018 Value Plan PDF
SBC - 2017 Consumer Option Summary of Benefits and Coverage, 2017 Consumer Option PDF
SBC - 2017 Standard Option Summary of Benefits and Coverage, 2017 Standard Option PDF
SBC - 2017 Value Plan Summary of Benefits and Coverage, 2017 Value Plan PDF
Transplant-related Travel Travel Reimbursement Request - Aetna Institute of Excellence Transplant Network only PDF
Wellness Incentive Account Reimbursement Form Form to receive reimbursement from your Wellness Incentive Account PDF
 
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