Are you eligible?
Answer the questions.
Please answer the following questions to help determine if you should apply. Your information will not be saved or used in any way by
What you will need:
- Total gross household income for everyone in your household (total income before taxes and deductions)
- Current amount you spend on your medication per year
Please keep a copy of your application after you have faxed or mailed it to the address provided on the form. If you want to check on the status of your application you will need the eligibility code affixed to the application.