This form is to be used for reimbursement of covered preventative prescription drugs only.
The Basic MEC plan does not include prescription drug coverage with the exception of preventive drugs as mandated by the Affordable Care Act (ACA). Preventative drugs are covered at, and will be reimbursed at, 100%.
Please complete this form and include a copy of your original payment receipt and proof of your prescription which may be a copy of the prescription or a copy of the prescription profile supplied by your pharmacist. SBMA will not process your claim if you do not include these items.
