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 (E-mails will be answered within one business day.)

It is our pleasure to serve you!


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 800-686-8425.

FSA Store and HSA Store simplify shopping for FSA- and HSA-eligible products. When you use your MedBen debit card at the FSA Store, you don’t need to substantiate your purchase!

FSA and HSA Stores remove the guesswork from determining if your purchase is qualified for reimbursement, and offer a 100% product eligibility guarantee.

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


Medical and Pharmacy

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 Employee Application – Apply or make coverage changes.

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


Employee’s Guide to Flexible Spending Accounts (with Debit Card) – Overview/FAQ of MedBen FSAs for plan participants who use MedBen debit cards.

Employee’s Guide to Flexible Spending Accounts (No Debit Card) – Overview/FAQ of MedBen FSAs for plan participants who don’t use MedBen debit cards.

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.

Health Care FSA Examples of Qualified Medical Expenses – Examples of services and medical products that can be purchased with FSA funds.

Limited Purpose Health Care FSA Examples of Qualified Medical Expenses – Examples of dental and vision services and products that can be purchased with limited purpose FSA funds.

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


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.

Request for Personal Identification Number – Request MedBen to provide a Personal Identification Number (PID) for a plan member.

PHI Disclosure Accounting 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.


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. (Please print and sign form before sending.)

Death Claim Form (Life Insurance Claim) – Please contact MedBen Customer Service (800-686-8425 or 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.


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.


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