Prescription Copay Claim Form

 Prescription Copay Claim Form


Please read the information under the Prescription Copay Information tab prior to submitting for reimbursement.  If you have any questions, please contact the SBF at (716) 881-5462.

 

 copay claim form

 

Click on the Image Above to Open and Print the Supplemental Benefit Fund Prescription Copay Claim Form

 

For more information regarding the SBF Prescription Copay Benefits, please see the Prescription Copay Information Section.