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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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2012
PHARMACY FORMULARIES
Self-funded groups use either the Focus
formulary or the Outcomes formulary. If you're not sure which
formulary your group is using, ask your Plan Administrator for
clarification or contact MedBen Customer Service at (800) 686-8425 or
medben@medben.com.
The Focus formulary offers the most
cost-effective drug options.
The Outcomes formulary offers broader
choice while still delivering significant cost savings.
(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.)
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2011
PHARMACY FORMULARIES
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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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