Specific Line-By-Line Instructions - Low-Cost Drug Program Application

*NOTE: If you were eligible for benefits under this program through February 29, 2000 and you are now a member of

a household where another person is qualified, you do not need to meet the age or disability requirements.

Household Size

Income Limit

$15,989

$21,541 $27,094

$32,647

$38,200 $43,753

$49,305

$54,858

If yes, and your household income

for 2002 will be less than 90% (.90) of your 2001 income and also less than the amounts listed above, write us a

letter. Tell us in your letter what your 2002 income will be, where that income will be coming from and why your

income is less than it was in 2001. Attach the letter to the front of your application that you filled out using your 2001

income. We will review your letter and see if you qualify for the Low-Cost Drug Program.

You must apply for the low-cost drug program every year.

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Parent category: Financial