Transcription of Special Pharmaceutical Benefits Program Application
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Special Pharmaceutical Benefits Program Application
Special Pharmaceutical Benefits Program Application The Special Pharmaceutical Benefits Program (SPBP) is administered by the Pennsylvania Department of Health. For more information regarding Program eligibility requirements, income limits or covered services, go to For questions about the Application or enrolling, call 1-800-922-9384 or send your questions to 1 Applicant Information Last name First name Middle initial Suffix (Sr., Jr., e tc.) SPBP ID number (if known) Preferred language EnglishSpanish Other Home address Include proof of residency with your Application . City State Zip Date of birth Social Security number Include proof of your Social Security number with your Application .
Program. Information is shared with claim processing vendors for the purpose of paying pharmaceutical and laboratory claims, if applicable, and for coordination of benefits. If you need help completing this application, please call 1-800-922-9384 or …
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