Form Hc 201p - Pharmacy Programs Application - Vermont Department For Children And Families
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2HC 201P
Vermont Department for Children and Families
R 10/04
Pharmacy Programs Application
VHAP-Pharmacy, VScript, VScript Expanded, and Healthy Vermonters Programs
This application is for pharmacy programs that help Vermonters pay for prescription drugs. All four programs help people who have a
disability or are 65 or older. The Healthy Vermonters program also helps others with moderate incomes. Depending on income, you may be
eligible for one of these four programs.
Program
VHAP-Pharmacy
VScript
VScript Expanded
Healthy Vermonters
Maximum Income*
$ 1,190 per month
$ 1,389 per month
$ 1,785 per month
$ 3,104 per month
You Receive
Prescription drugs
Long-term maintenance drugs and Healthy Vermonters benefit
Prescription drugs
You pay
Discounted rate
$13 per month
$17 per month
$35 per month
for each drug
per person
* Maximum income shown is for one-person household. Maximum income increases with each additional household member.
Name ______________________________________________________________________ Phone No. ___________________________
LAST
FIRST
MIDDLE INITIAL
Mailing Address ___________________________________________________________________________________________________
NUMBER
STREET
P.O. BOX OR RD
CITY OR TOWN
STATE
ZIP CODE
Marital status
Sex
M
F
SINGLE
MARRIED
CIVIL UNION
SEPARATED
DIVORCED
WIDOWED
Spouse’s or civil
union partner’s name ___________________________________ Sex
M
F
Is this person also applying?
Yes
No
IF LIVING WITH YOU
Are any of your children or stepchildren living with you who are under age 21?
Yes Age of children ________________
No
Please answer the questions below for the people applying for coverage.
QUESTIONS
APPLICANT
SPOUSE OR CIVIL UNION PARTNER
What is your social security number?
What is your date of birth?
Are you a U.S. citizen?
Yes
No
Yes
No
Do you receive Medicare?
Yes
No
Yes
No
Start date
Medicare claim number
Premium amount
Do you receive SSI?
Yes
No
Yes
No
Do you have private insurance that covers
prescription drugs? (Do not include
discount programs)
Yes
No
Yes
No
Name of insurance company
Street address
City and state
Policy number
Does this drug coverage have an annual limit?
Yes
No
Yes
No
Healthy Vermonters allows you to have prescription drug insurance, but you may not use the program until you have reached your annual limit
on your other insurance. If you have prescription drug insurance, you are not eligible for VHAP-Pharmacy, VScript, or VScript Expanded. If
you are thinking of dropping or changing your coverage to become eligible, you may want to call the Area Agency on Aging at 1-800-642-5119
(V/TTY) or the Health Care Ombudsman at 1-800-917-7787 to discuss if that would be to your benefit.
Please complete the other side and sign this application
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