Plan Members

Health Care Planning Made Easy.

 

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A Stress-Free Experience.

As your health plan’s benefits administrator, MedBen is here to help. From prompt claims payments to knowledgeable customer service, we always strive to give you a stress-free experience.

On this page you’ll find links to various resources to assist you with your benefits coverage. Should you have a question or need something that’s not available below, please contact MedBen Customer Service at 800-686-8425 or medben@medben.com. (E-mails will be answered within one business day.)

It is our pleasure to serve you!

ONLINE SERVICES AND RESOURCES

Use this secure 24/7 service portal to access claims and benefits information. If you need assistance logging in to MedBen Access or using its features, please contact MedBen Customer Service at 888-686-8425.

A detailed list of qualified medical expenses under Section 213 of the Internal Revenue Code.

When the opening screen appears, simply type in the MedBen password mbc26 (case sensitive) and press the “Enter” button on your keyboard.

If you have any questions regarding qualified medical expenses under your MedBen plan, please contact MedBen Specialty Services Customer Service at 800-297-1829 or admin@medben.com.

FORMS AND APPLICATIONS

Medical
Dental

Dental Employee Application – Apply or make coverage changes.

Dental AND Vision Employee Application  Apply for dental and/or vision coverage or make coverage changes.

Vision

Vision Employee Application – Apply or make coverage changes.

Vision AND Dental Employee Application  Apply for dental and/or vision coverage or make coverage changes.

FSA

Employee’s Guide to Flexible Spending Accounts – Overviews/FAQs of MedBen FSAs for plan participants 

FSA Mileage Reimbursement Form – For claiming under your Health FSA the mileage used to obtain qualified medical services from a physician, hospital or facility to prevent or alleviate a physical disease, defect or illness.

Debit Card Substantiation Form – Substantiate purchases made with your MedBen Debit Card.

Orthodontia Services Reimbursement Request Form – An orthodontist (or authorized bookkeeper) can use this form to request reimbursement for services.

Request for Debit Card – Request a debit card for your dependent or replace a lost or stolen card.

Sample Letter of Medical Necessity  If a Letter of Medical Necessity is required from your provider to receive reimbursement from your FSA, this sample letter can be used for that purpose. Simply print out/save and give to your doctor.

FSA Reimbursement Request Form – Used when requesting reimbursement from a Health FSA plan, Limited Purpose FSA plan and/or Dependent Care reimbursement plan.

HRA

HRA Reimbursement Request Form – Request reimbursement from your HRA account. NOTE: This form is generic and may not be specifically based on your employer’s HRA plan design.

COBRA

COBRA Qualifying Event Form – Notifies MedBen of a COBRA qualifying event.

HIPAA

Access to Personal Information Request Form – Request access to copy or inspect personal health information held by MedBen.

Request to Restrict Uses and Disclosures of Protected Health Information – Request restrictions of the use or disclosure of personal health information held by MedBen.

Accounting of Protected Health Information Request Form – Request an accounting of disclosures made by MedBen of your health and medical information.

Confidential Communication Request Form – Request alternate means of communication with MedBen.

PHI Amendment Request Form – Request MedBen to make corrections or amendments to your protected health information.

Privacy Complaint FormRegister a complaint if you believe anyone at MedBen has inappropriately used or disclosed protected health information.

Other

Disability Claim Form – Plan members can submit a claim for long-term or short-term disability benefits.

Transportation Reimbursement Form – Plan members can request reimbursement from their transportation compensation account.

Notice of Appeal/Designation of Authorization Form – Plan members wishing to file a formal appeal of a disputed claim should use this form. They can also designate another entity to file an appeal on their behalf.

Death Claim Form (Life Insurance Claim) – Please contact MedBen Customer Service (800-686-8425 or medben@medben.com) to obtain a death claim form. Employers must complete and return this form (accompanied by a certified copy of the death certificate) in order for designated beneficiary to receive life insurance benefits.

RX FORMULARIES

blue and white pills spilling from bottleA formulary defines the copayment tier status of the medicines most commonly prescribed. Tier 1 medicines require the lowest member copayment.

MedBen clients who use Ventegra or Pharmacy Data Management, Inc. (PDMI) as their Rx network for their pharmacy plan can request the most recent formulary from their Human Resources representative or by calling MedBen Customer Service at 800-686-8425.

MedBen clients who use Rx networks other than Ventegra or PDMI can typically find formulary information on that network’s website. Visit the Networks page for pharmacy network links.

NETWORKS

Visit the Networks page for links to medical, pharmacy, vision and dental networks.