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The
following forms are for the use of fully-insured group
members based in Michigan.
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If your group is based in Indiana,
click here.
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If your group is based in
Ohio, click
here.
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If your group is based in
West Virginia, click
here.
 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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To
download a 2008 pharmacy formulary list, click
here
for a list arranged by drug class.
(If you are a self-funded group member, please visit the MedBen
Administrators Forms page here.) |
All forms measure
8½”x11”
unless otherwise
indicated.
Forms open in a new browser window.
MedBen
Employer Application
Employers should use this form to apply for
group health insurance coverage under a MedBen-sponsored plan.
MedBen
Employee Applications
New and existing employees of a
group insured by MedBen should use one of the forms below to apply
for health coverage for themselves and their dependent(s). (If you
are not certain of the number of covered lives in your group, use
the "Less Than 50 Covered Lives" form or ask your plan
representative.)
Less
Than 50 Covered Lives Enrolling
Large
Group (50+ Covered Lives)
MedBen Dental Employee Application
New and existing employees of a group covered under MedBen Dental
should use this form to apply for dental coverage for themselves and
their dependent(s). This form is also used to make changes (name,
address) to personal information and add/delete dependents
to/from MedBen Dental coverage.
Prescription Drug Reimbursement Form
Employees with MedBen prescription drug coverage should use this form to
request reimbursement for a prescription drug claim.
Prescription Drug Mail Order Form
Employees with MedBen prescription drug coverage should use this form
to purchase mail-order prescription drugs.
MedBen
Mutual Forms • MedBen
Administrators Forms
MedBen
Specialty Services Forms • MedBen
Dental and VisionPlus Forms |