The following forms are for the use of fully-insured group members based in Michigan.

  • If your group is based in Indiana, click here.

  • If your group is based in Ohio, click here.

  • If your group is based in West Virginia, click here.

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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.

2012 PHARMACY FORMULARIES

(If you are a self-funded group member, please visit the MedBen Administrators Forms page.)
 

2011 PHARMACY FORMULARIES

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.

Death Claim Form (Life Insurance Claim) 
Please contact MedBen Customer Service (800-868-8425 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.

MedBen Mutual Forms • MedBen Administrators Forms
MedBen Specialty Services Forms • MedBen Dental and VisionPlus Forms