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Get NJ AP-2 2016-2024

If a Part D plan is the primary payer for a drug covered on its formulary PAAD will provide coverage as secondary payer if needed for that drug and the PAAD beneficiary will pay the regular PAAD copayment for PAAD covered drugs. PAAD co-pay is 5 per PAAD covered generic drug Senior Gold co-pay for Senior Gold covered drugs is 15 50 of the remaining cost of the prescription or actual drug cost whichever is less. For More Information Visit www. njpaad.gov or www. njsrgold. gov Or Call 1-800-792-9745 AP-2 Instructions DEC 14 2015 COMPARISON OF PAAD AND SENIOR GOLD 1-800-792-9745 Disabled Program www. This application is ONLY for people who are applying for PAAD or Senior Gold benefits for the first time. If it appears that you may be eligible for USF LIHEAP the Extra Help SLMB/SLMB QI-1 and/or NJ SNAP PAAD will forward your information to these programs for eligibility consideration. Turn this page over for a comparison of PAAD and Senior Gold. Once you are on the PAAD program you may qualify for a property tax freeze reduced motor vehicle fees and Communications Lifeline. Hearing Aid Assistance to the Aged and Disabled PAAD eligibles that purchase a hearing aid may receive a 100 payment to offset the cost of purchase. O. Box 715 Trenton NJ 08625-0715 www. nj. gov/humanservices UNIVERSAL APPLICATION FOR PAAD SENIOR GOLD AND OTHER SPECIAL BENEFIT PROGRAMS By filling out the attached application you may be eligible for benefits provided by the Pharmaceutical Assistance to the Aged and Disabled PAAD or the Senior Gold Prescription Discount programs. Further by filling out this application you will be screened for benefits provided by the Universal Service Fund USF and the Low-Income Home Energy Assistance Program LIHEAP two more programs that help pay for utility costs. In addition you will be screened for Extra Help with Medicare Prescription Drug Plan Costs a program that helps pay Medicare Part D costs the Specified Low-Income Medicare Beneficiary SLMB or SLMB Qualified Individual programs two programs that pay Medicare Part B premiums and the New Jersey Supplemental Nutrition Assistance Program NJ SNAP also known as Food Stamps this program provides supplemental nutrition assistance to help people who meet certain income criteria buy groceries. Co-pay will change with change in drug price. Catastrophic cap does not apply. If Medicare-eligible must enroll in a Medicare Part D Prescription Drug Plan unless prohibited from doing so. formulary Senior Gold will provide coverage as secondary payer if needed for that drug and the Senior Gold beneficiary will pay the regular Senior Gold copayment for Senior Gold covered drugs. Please follow these instructions to ensure that your application is processed quickly and accurately. Use blue or black ink. Do not use red ink or pencil* Print clearly in uppercase block letters see examples below. Print only one number or letter in each box. Stay inside boxes. Correct errors with white correction fluid* A B C D E F G H I K L M N O P Q R S T U V W X Y Z J If you have questions or need help filling out this form call toll free 1-800-792-9745.

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