EBA Enrollment Portal

Updated 5/23/18

 

View Policy Cost
& Benefits

MEC

DRUG COVERAGE OPTIONS

This plan is not insurance.  This is a co-pay discount card. Formulary may not be accurate and change quarterly.

  • $25 Individual

  • $35 Individual/Spouse/Children

Fully Insured RX copay plan This plan may not be available in all states.


Prefer to submit your application by Email?

Download the application below,
fill it out, and send it to info@essentialbenefitplans.com.


Would you like to upload a census?

Agent's Name *
Agent's Name

Plan & Enrollees

Please choose carefully. EE: Individual | ES: Individual & Spouse | EC: Individual & Child(ren) | EF: Family

Primary Policy Holder

Effective Date *
Effective Date
Date of Birth *
Date of Birth
Gender *
Address *
Address
Phone *
Phone

Spouse

Date of Birth
Date of Birth
Gender

Dependent One

Date of Birth
Date of Birth
Gender

Dependent Two

Date of Birth
Date of Birth
Gender

Dependent Three

Date of Birth
Date of Birth
Gender

Signatures

Terms & Conditions *
Payment Authorization *
Electronic Signature *
Electronic Signature
By writing my name below, I, the policy holder certify that I am above the age of 18, and have completed this form acuratly and the best of my knowledge.
Today's Date *
Today's Date

Payment Information

There is not a charge to use a bank account.
Located on the back, next to the signature.
5% Credit Card Premium Fee *
$
Please reference downloadable PDFs on the top left for price matrix.
There is a one-time application fee.
Rx Flex Card
RX Flex Card copay discount card. This plan is not insurance. The formulary may not be accurate and change quarterly.
Fully Insured RX co-pay plan. This plan may not be available in all states. It has very low co-pays and is the only fully insured RX program available to individuals on the open market. Price: See plan description for details.
Total cost of plan.