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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.

Member Forms & Documents
Title Description Download
Plan Brochure OPM Brochure - Standard Option and Value Plan 2019 PDF
Plan Brochure OPM Brochure - Consumer Option 2019 PDF
SBC - 2019 Standard Option Summary of Benefits and Coverage, 2019 Standard Option PDF
SBC - 2019 Value Plan Summary of Benefits and Coverage, 2019 Value Plan PDF
SBC - 2019 Consumer Option Summary of Benefits and Coverage, 2019 Consumer Option PDF
Prescription Drug List Prescription Drug Guide/Formulary PDF
Prescription Drug List Advanced Control Specialty Formulary PDF
Prescription Drug List Specialty Prescription Drug List 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 Provider Nomination Form PDF
Member Form Travel Reimbursement Request - Aetna Institute of Excellence Transplant Network Only 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 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

Quality Management Documents
Title Description Download
Member Document CAHPS Member Satisfaction Scores PDF
Member Document HEDIS Clinical Performance Scores PDF
Member Document Program Description - Quality Management FEHBP PDF
Member Document Provider Satisfaction Post-Call Survey Scores - San Antonio, TX PDF
Member Document Provider Satisfaction Post-Call Survey Scores - Scottsdale, AZ PDF
 
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