Paad Form – Fill Out and Use This PDF

New Jersey Department of Human Services

Pharmaceutical Assistance to the Aged and Disabled (PAAD),

Lifeline and Special Benefit Programs

Senior Gold Prescription Discount Program (Senior Gold)

P.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. This application is ONLY for people who are applying for PAAD or Senior Gold benefits for the first time. If you are married, and you and your spouse wish to apply for benefits, each of you must complete a separate application.

PAAD and Senior Gold are state-funded prescription programs that help eligible New Jersey residents with the cost of prescribed medication (including insulin, insulin needles, and needles for injectable medicines used for the treatment of multiple sclerosis).

While you are applying for assistance with your prescription costs by filling out this application, you may be eligible for several other valuable benefits if you are eligible for PAAD. For example, if eligible for PAAD, you may be eligible for benefits through the Lifeline utility assistance and Hearing Aid Assistance to the Aged and Disabled programs.

Once you are on the PAAD program, you may qualify for a property tax freeze, reduced motor vehicle fees, and Communications Lifeline.

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.

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.

For More Information,

Visit www.njpaad.gov or www.njsrgold.gov

Or, Call 1-800-792-9745

AP-2 (Instructions)

JAN 16

2016 COMPARISON OF PAAD AND SENIOR GOLD

1-800-792-9745

	Pharmaceutical Assistance to the Aged and
				Senior Gold Prescription Discount Program
	Disabled Program
					www.njsrgold.gov
	www.njpaad.gov
	PAAD beneficiaries must fill out all pages of this application.		Senior Gold beneficiaries do not qualify for the Lifeline
			Credit/Tenants Lifeline Assistance Program or the Hearing
			Aid Assistance to the Aged and Disabled Program and,
			therefore, do not need to answer questions 24, 25, 26 and
			27 of this application.
	Income limit: less than $26,575 (single)		Income limit: between $26,575 and $36,575 (single)
	less than $32,582 (married)			between $32,582 and $42,582 (married)
	ID Number starts with 6.		ID Number starts with 7.
	PAAD co-pay is:		Senior Gold co-pay for Senior Gold covered drugs is $15 +
	∙ $5 per PAAD covered generic drug		50% of the remaining cost of the prescription or actual drug
	∙ $7 per PAAD covered brand name drug.		cost, whichever is less. (Co-pay will change with change in
			drug price.)
	Catastrophic cap does not apply.		Catastrophic cap:		$2,000 (single)
					$3,000 (married)
			Once the beneficiary‟s annual out of pocket expenses reach
			the catastrophic cap, co-pay is $15 (or the reasonable cost
			of the drug, whichever is less) for the balance of that
			eligibility period.
	If Medicare-eligible, must enroll in a Medicare Part D		If Medicare-eligible, must enroll in a Medicare Part D
	Prescription Drug Plan unless prohibited from doing so.		Prescription Drug Plan unless prohibited from doing so.
	If a Part D plan is the primary payer for a drug covered on its		If a Part D plan is the primary payer for a drug covered on its
	formulary, PAAD will provide coverage as secondary payer if		formulary, Senior Gold will provide coverage as secondary
	needed for that drug, and the PAAD beneficiary will pay the		payer if needed for that drug, and the Senior Gold
	regular PAAD copayment for PAAD covered drugs.		beneficiary will pay the regular Senior Gold copayment for
			Senior Gold covered drugs.
	However, if a Part D plan does not pay for a medication
	because the drug is not on its formulary, PAAD beneficiaries		However, if a Part D plan does not pay for a medication
	will have to switch to a drug on their Part D plan‟s formulary,		because the drug is not on its formulary, Senior Gold
	or their doctor will have to request an exception due to		beneficiaries will have to switch to a drug on their Part D
	medical necessity directly to the Part D plan.		plan‟s formulary, or their doctor will have to request an
			exception due to medical necessity directly to the Part D
			plan.
	Third-party insurance must be billed BEFORE PAAD.		Third-party insurance must be billed BEFORE Senior Gold.
	PAAD DOES NOT pay for diabetic testing supplies (for		Senior Gold DOES NOT pay for diabetic testing supplies (for
	example, test strips and lancets).		example, test strips and lancets).

AP-2 (Instructions)

JAN 16

New Jersey Department of Human Services

Pharmaceutical Assistance to the Aged and Disabled (PAAD),

Lifeline and Special Benefit Programs

Senior Gold Prescription Discount Program (Senior Gold)

This form will be scanned for computerized data capture. 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

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Y

Z

1

2

3

4

5

6

7

8

9

0

If you have questions or need help filling out this form, call toll free 1-800-792-9745.

DO NOT SEND ORIGINAL SUPPORTING DOCUMENTS. SEND COPIES.

ORIGINALS WILL NOT BE RETURNED.

Please see reverse for list of necessary documents.

AP-2 (Instructions)

JAN 16

You must submit proof with this form.

Processing will be delayed if all necessary documents are not sent with this form.

If you are applying for PAAD or Senior Gold supply the following documents:

∙Proof of age (must show date of birth)

∙Proof of current Social Security disability benefits if over age 18 and under age 65

∙Proof of principal place of residence, dated within the last 6 months

∙Copy of your Medicare Card

∙Copy of the front and back of each health and prescription insurance card(s).

PAAD, Lifeline, HAAAD and Senior Gold programs require individuals be aged 65 or older OR over age 18 and under age 65 and receiving Social Security Disability benefits.

	If you are 65 years of age or older…			Send proof of date of birth.
If you are over age 18 and under age 65 AND				Send proof of date of birth AND proof of current disability status.
	you receive Social Security Disability…
Submit a COPY of one of the following to document DATE OF BIRTH:
∙	Birth Certificate	∙	Social Security record that indicates your date of birth
∙	Baptismal Certificate	∙	Railroad Retirement record that indicates your date of birth

If you cannot supply the above document(s), copies of any TWO of the following that indicate DATE OF BIRTH will be acceptable.

∙	Driver’s License	∙	Delayed Birth Certificate	∙	State or Federal Census record	∙	School Record
∙	Foreign Passport	∙	Voting record	∙	Marriage Record	∙	Insurance Policy

If you receive Social Security Disability, ALSO submit a COPY of one of the following to document disability status:

∙Social Security Award Certification (SSA-L30) issued by the Social Security Administration within the last six months

∙Verification through a benefit verification letter which indicates your current Social Security Disability status. You may obtain this letter by calling the Social Security Administration toll-free at 1-800-772-1213 (TTY 1-800-325-0778)

If you are applying for Lifeline Utility Credit/Tenants Lifeline Assistance Program, supply the following documents:

∙Copy of your current gas and electric bill(s) if you are a utility customer, or

∙Copy of your current lease agreement, if your rent includes the cost of electric/gas, and

∙List the monthly amount of rent that you pay on Page 9 of the application.

If you are also applying for assistance from the Universal Service Fund (USF)/Low-Income Home Energy Assistance Program (LIHEAP), supply the above documents plus the following:

∙If your home‟s primary source of heat is not gas/electric, submit a copy of your last bill from your heating supplier (e.g. oil, propane or wood supplier).

Please Note: In certain cases, additional documentation may be required.

AP-2 (Instructions)

JAN 16

New Jersey Department of Human Services

Pharmaceutical Assistance to the Aged and Disabled (PAAD), Lifeline and

Special Benefit Programs/Senior Gold Prescription Discount Program (Senior Gold)

PO Box 637, Trenton, NJ 08646-0637

Toll Free Hotline 1-800-792-9745

PLEASE PRINT YOUR NAME ON THE TOP OF EACH PAGE.

1.Enter your name, date of birth and sex. List your Social Security number. Use CAPITAL LETTERS. Print only one letter or number in each box. List date of birth verified by Social Security.

2.If your spouse is also applying, both of you must complete separate applications. Even if your spouse is not applying, we need all of the questions answered and signatures for both of you, if

married and living together.

Spouse’s

Suffix

Last

(Jr., Sr.,

Name

etc.)

First

Middle

Sex

Name

Initial

Male/Female

Spouse’s

Month

/

Day /

Year

Social

-

-

Date of

Security

Birth

/

/

Number

3. Please identify your current marital status. Please

only one box.

X

*If you are separated from your spouse, call the toll-free number above to request form „Affidavit of Separation‟ which MUST accompany this application.

AP-2
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