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This page allows
self-funded group members to download our most frequently used forms.
 All
forms are saved in the .PDF format. To view and print a form requires Adobe
Acrobat Reader. You can download a free copy of Reader by clicking here.
If you have any questions about what forms your group uses,
contact the MedBen Customer Service Department at 800-686-8425 or medben@medben.com. For
technical questions relating to downloading and printing of forms, e-mail this site's
webmaster at chuckj@medben.com.
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2008
PHARMACY FORMULARIES
If
your group uses a single tier or two tier plan, or a three tier copay
plan with less than a $15 member copay difference between tier 2 and
tier 3, click here
for an OUTCOMES FORMULARY arranged by drug class.
If
your group uses a three tier copay plan with a $15 member copay
difference between tier 2 and tier 3, click here
for a FOCUS FORMULARY arranged by drug class. (If
your group uses Express Scripts PBM, please visit their web site
at www.expressscripts.com
to obtain a formulary list. If
you are a fully-funded group member, please visit the MedBen Mutual
Forms page here.) |
All forms measure
8½”x11”
unless otherwise
indicated.
Forms open in a new browser window.
MedBen
Administrators Claim Form
Use this form to submit a claim for
incurred medical or hospital expenses.
Vision
Claim Form
Use this form to submit a claim for
incurred expenses covered under a MedBen Vision plan.
Dental
Claim Form
Use this form to submit a claim for
incurred expenses covered under a MedBen Dental plan.
Disability
Claim Form
Use this form to submit a claim for
long-term or short-term disability benefits.
MedBen
Administrators Employee Application
New and existing employees of a group
administered by MedBen should use this form to apply for health coverage for
themselves and their dependent(s).
MedBen
Change Request Form
Use this form to add/remove a spouse or
other dependent(s) to/from employee coverage, or notify MedBen of a change in
name, address, or marital status.
Notice of Appeal/Designation of
Authorization Form
Employees wishing to file an formal appeal of a
disputed claim should use this form. They can also
designate another entity to file an appeal on their behalf.
MedBen
Mutual Forms • MedBen
Administrators Forms
MedBen
Specialty Services Forms • MedBen
Dental and VisionPlus Forms
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