Form Hc 201p - Pharmacy Programs Application Form - Vermont Department For Children And Families
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2Vermont Department for Children and Families
Economic Services Division
Pharmacy Programs Application
VPharm, VHAP-Pharmacy, VScript, VScript Expanded, and Healthy Vermonters Programs
This application is for programs that help Vermonters pay for prescription drugs. People who have a disability or are age 65 or older may be eligible for
one of these programs. The Healthy Vermonters program helps people of all ages. We will give you the best coverage we can.
The maximum income limit for one person is about $3,600 per month, increasing with each additional household member. You may be required to pay a
monthly premium of up to $50 per month for each person. Please answer each question below for the people applying for coverage.
Name __________________________________________________________________ Social Security no. ________________________
Last
First
Middle initial
Mailing address ___________________________________________________________________________________________________
Number
Street
PO Box or RD
City or Town
State
Zip code
Marital status
Sex
M
F
SIngle
Married
Civil union
Separated
Divorced
Widowed
Spouse or CU partner __________________________________________ Social Security no. ________________________
Last
First
Middle initial
Is this person also applying?
Yes
No
Telephone # _______________________
Are any of your children or stepchildren who are under age 21 living with you?
Yes - ages of children________________
No
QUESTIONS
APPLICANT
SPOUSE OR CIVIL UNION PARTNER
1. What is your date of birth?
2. Are you a U.S. citizen? If no, include proof of immigrant status.
Yes
No
Yes
No
3. Do you have Medicare?
Yes
No
Yes
No
3a. Medicare claim number
Begin
Begin
3b. Part A (hospital coverage)
date
date
Premium
Premium
Begin
Begin
3c. Part B (medical coverage)
date
Premium
date
Premium
Begin
Begin
3d. Part C (managed care)
Premium
Premium
date
date
Begin
Begin
3e. Part D (drug coverage)
date
Premium
date
Premium
4. Have you chosen a Part D Prescription Drug Plan?
Yes
No
Yes
No
4a. Plan name
4b. Contract ID #
4c. Plan ID #
4d. Plan start date
5. Have you applied for “extra help” for Part D through
Yes, granted
Yes, granted
Social Security?
Yes, denied
No
Yes, denied
No
5a. If granted, begin date
Over
Over
Failed to
Over
Over
Failed to
cooperate
cooperate
income
resource
income
resource
5b. If denied, what reason did Social Security give you?
Other;
Other;
explain:
explain:
Over income
Over resource
Over income
Over resource
6. If you did not apply, what was your reason?
Other;
Other;
explain:
explain:
7. Do you have insurance that covers prescription drugs?
Yes
No
Yes
No
(Do not include discount programs)
7a. Name of insurance company
7b. Address
7c. Policy number
7d. Date coverage began
7e. Does this drug coverage have an annual limit?
Yes
No
Yes
No
HC 201P R01/10
Please complete the other side and sign this application
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