Plan Member Forms

The following Midwest Security forms and form descriptions are provided for the use of our health plan members only. If you are a Midwest Security health plan member and have questions concerning the use of these forms, please contact your Midwest Security Customer Service Center.

• Full Time Student Update Form
This completed form should be returned to Midwest Security Life Insurance Company. It is used to verify full time student status. Eligible dependent children are automatically covered on the plan to age 19. After age 19, coverage may be extended to the age of 23 or 25 if the child meets the eligibility requirements outlined in the policy. A possible requirement may be full time student status.


• Pre-existing Condition Form
This completed form should be returned to Midwest Security Life Insurance Company. It is used to verify pre-existing conditions. A pre-existing condition is defined as a condition, disease or ailment for which you received medical care, treatment, services, medication, diagnosis or consultation within 6 or 12 months immediately preceding your enrollment date, based on the benefits outlined in your policy.


• Coordination of Benefits Update Form
This completed form should be returned to Midwest Security Life Insurance Company. It is used to coordinate benefits between insurers. Coordination of benefits prevents a covered person from receiving health plan benefits that exceed actual costs.

Prescription Forms:

• Prescription Reimbursement Form
This completed form should be returned to the Medco Health address provided on the form. Use this form to request reimbursement if you paid your pharmacy the full cost of your prescription medication.


• Prescription Coordination of Benefits Form/Direct Claim Form
This completed form should be returned to the Medco Health address provided on the form. It is used to coordinate benefits between prescription drug program insurers.

The above documents are available in Adobe Portable Document Format (PDF). If you don't already have a PDF viewer installed, a free version is available from Adobe Software. The free Adobe ® Acrobat ® Reader allows you to view, navigate, and print PDF files across all major computing platforms. To print a PDF document, click the printer icon button in the Adobe Acrobat menu bar, directly above the displayed document.