Benefits Checkup

A Service of the National Council on Aging

Application Forms Center

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Program Name Sort Application Name Sort State Sort Revision Date Sort
Alaska Senior Benefits
Application Form in English
AK
11/01/07
Arizona CoppeRx CardSM
Online Application in English
AZ
Arizona CoppeRx CardSM
Brochure and Temporary CoppeRx Card in English
AZ
Arizona CoppeRx CardSM
Brochure and Temporary CoppeRx Card in Spanish
AZ
Connecticut Pharmaceutical Assistance Contract to the Elderly and Disabled - (ConnPACE)
Application Form in English
CT
12/01/09
Connecticut Pharmaceutical Assistance Contract to the Elderly and Disabled - (ConnPACE)
Instructions in English
CT
12/01/09
Connecticut Pharmaceutical Assistance Contract to the Elderly and Disabled - (ConnPACE)
Application Form in Spanish
CT
12/01/09
Connecticut Pharmaceutical Assistance Contract to the Elderly and Disabled - (ConnPACE)
Instructions in Spanish
CT
12/01/09
Delaware Prescription Assistance Program (DPAP)
Fillable! Application Form in English
DE
Florida Discount Drug Card Program
Online Application in English
FL
Hawaii Rx Plus
Application Form in English
HI
04/01/06
Illinois Cares Rx
Fillable! Application Form in English
IL
12/01/09
Illinois Cares Rx
Instructions and Application Form in English (Part 1)
IL
12/01/09
Illinois Cares Rx
Instructions and Application Form in English (Part 2)
IL
12/01/09
Illinois Cares Rx
Online Application in English
IL
Illinois Rx Buying Club
Application Form in English
IL
02/01/09
HoosierRx
Fillable! Application Form in English
IN
02/01/09
Prescription Advantage Program
Application Form in English
MA
06/01/07
Prescription Advantage Program
Application Form in Spanish
MA
06/01/07
Prescription Advantage Program
Application Form in Albanian
MA
06/01/07
Prescription Advantage Program
Application Form in Chinese
MA
06/01/07
Prescription Advantage Program
Application Form in Haitian Creole
MA
06/01/07
Prescription Advantage Program
Application Form in Khmer
MA
06/01/07
Prescription Advantage Program
Application Form in Portuguese
MA
06/01/07
Prescription Advantage Program
Application Form in Russian
MA
06/01/07
Prescription Advantage Program
Application Form in Vietnamese
MA
06/01/07
Maryland Senior Prescription Drug Assistance Program (SPDAP)
Application Form in English
MD
11/13/09
Low Cost Drugs for the Elderly or Disabled Program (DEL)
Application Form in English (Multi-Program)
ME
07/01/07
Maine Rx Plus
Application Form in English (Multi-Program)
ME
07/01/07
MiRx Card - Michigan's Prescription Drug Discount Card
Brochure and Application Form in English
MI
Missouri Rx Plan
Application Form in English
MO
07/01/09
Missouri Rx Plan
Application Form in Spanish
MO
07/01/09
Montana Big Sky Rx Program
Application Form in English
MT
02/01/09
NCRx
Application Form in English
NC
Pharmaceutical Assistance to the Aged and Disabled Program (PAAD)
Application Form in English (Multi-Program)
NJ
04/01/09
Senior Gold Prescription Discount Program
Application Form in English (Multi-Program)
NJ
04/01/09
Senior Rx
Fillable! Application Form in English
NV
Senior Rx
Application Form in Spanish
NV
04/01/09
EPIC - Elderly Pharmaceutical Insurance Coverage
Fillable! Application Form in English
NY
06/01/02
EPIC - Elderly Pharmaceutical Insurance Coverage
Fillable! Application Form in Spanish
NY
10/01/00
NYP$ - New York Prescription Saver
Online Application in English
NY
NYP$ - New York Prescription Saver
Online Application in Spanish
NY
NYP$ - New York Prescription Saver
Application Form in English
NY
12/01/08
NYP$ - New York Prescription Saver
Application Form in Spanish
NY
12/01/08
Ohio's Best Rx
Online Application in English
OH
Ohio's Best Rx
Application Form in English
OH
02/01/08
Ohio's Best Rx
Application Form in English - Large Print
OH
02/01/08
Ohio's Best Rx
Application Form in Spanish
OH
01/01/08
Ohio's Best Rx
Application Form in Somali
OH
01/01/08
Oregon Prescription Drug Program
Online Application in English
OR
Oregon Prescription Drug Program
Online Application in Spanish
OR
Oregon Prescription Drug Program
Application Form in English
OR
01/08/09
Oregon Prescription Drug Program
Application Form in Spanish
OR
Oregon Prescription Drug Program
Application Form in Vietnamese
OR
01/08/09
PACE (Pharmaceutical Assistance Contract for the Elderly)
Online Application in English
PA
PACE (Pharmaceutical Assistance Contract for the Elderly)
Application Form in English
PA
01/01/09
PACE (Pharmaceutical Assistance Contract for the Elderly)
Application Form in Spanish
PA
PACENET (Pharmaceutical Assistance Contract for the Elderly)
Application Form in English
PA
01/01/09
PACENET (Pharmaceutical Assistance Contract for the Elderly)
Application Form in Spanish
PA
PACENET (Pharmaceutical Assistance Contract for the Elderly)
Online Application in English
PA
South Carolina Gap Assistance Prescription Program for Seniors (GAPS)
Online Application in English
SC
South Carolina Gap Assistance Prescription Program for Seniors (GAPS)
Application Form in English
SC
01/01/10
Healthy Vermonters Program
Application Form in English (Multi-Program)
VT
01/01/10
Healthy Vermonters Program
Application Form in English (Rx Assistance Only)
VT
01/01/10
Prescription Drug Program: VHAP-Pharmacy
Application Form in English (Multi-Program)
VT
01/01/10
Prescription Drug Program: VHAP-Pharmacy
Application Form in English (Rx Assistance Only)
VT
01/01/10
Prescription Drug Program: VScript
Application Form in English (Multi-Program)
VT
01/01/10
Prescription Drug Program: VScript
Application Form in English (Rx Assistance Only)
VT
01/01/10
Prescription Drug Program: VScript-expansion
Application Form in English (Multi-Program)
VT
01/01/10
Prescription Drug Program: VScript-expansion
Application Form in English (Rx Assistance Only)
VT
01/01/10
VPharm - Level 1
Application Form in English (Multi-Program)
VT
01/01/10
VPharm - Level 1
Application Form in English (Rx Assistance Only)
VT
01/01/10
VPharm - Level 2
Application Form in English (Multi-Program)
VT
01/01/10
VPharm - Level 2
Application Form in English (Rx Assistance Only)
VT
01/01/10
VPharm - Level 3
Application Form in English (Multi-Program)
VT
01/01/10
VPharm - Level 3
Application Form in English (Rx Assistance Only)
VT
01/01/10
Washington Prescription Drug Program
Online Application in English
WA
Washington Prescription Drug Program
Online Application in Spanish
WA
Washington Prescription Drug Program
Fillable! Application Form in English
WA
Washington Prescription Drug Program
Application Form in Spanish
WA
04/01/07
Wisconsin SeniorCare Program
Application Form in English
WI
07/01/08
Wisconsin SeniorCare Program
Instructions in English
WI
07/01/08
Wisconsin SeniorCare Program
Instructions in Spanish
WI
07/01/08
Wisconsin SeniorCare Program
Instructions in Hmong
WI
07/01/08
Wisconsin SeniorCare Program
Instructions in Russian
WI
07/01/08
Governor's Golden Mountaineer Discount Card Program
Online Application in English
WV
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