Official MHBP plan documents
Plan brochures, forms and documents to help you with your benefits.
All available documents are clickable below. If an item is not clickable, it is not available at this time.
Member plan brochures
Retiree documents
- 2025 Retiree plan brochure PDF - opens in a new window
- 2025 Medicare – Evidence of Coverage PDF - opens in a new window
- 2025 Medicare – Plan Document Notice PDF - opens in a new window
- 2025 Medicare – Schedule of Cost Sharing PDF - opens in a new window
- 2025 Medicare – Summary of Benefits PDF - opens in a new window
- 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
SilverScript (EGWP) Employer PDP Documents
Prescription
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
- 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
- PDP Disenrollment form PDF - opens in a new window
Note: Once your disenrollment is effective, you will no longer have prescription drug coverage under your MHBP PSHB plan. Prior to disenrolling, please call Member Services at 1-866-241-0262 (TTY: 711).
- 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.
- 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
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