Assistance Forms

Do I qualify for Medicare?

Most people qualify for Medicare due to the following situations: reached age 65 years or older and can receive benefits based on employment history (or spouse's), disability (disabled adult child or more than 24 consecutive months of disability, HIV/AIDS, or a chronic disease such as End Stage Renal Disease). 

Contact the Social Security Administration to see if you qualify: visit or call  1-800-772-1213

Do you already have Medicare? Answer the questions below to see if you may qualify for additional assistance.

  • Is your income below $1,313 (individual)/$1,765 (married)? Are your assets below $6,940 (individual)/$10,410 (married)?

If "YES," you may qualify for assistance paying for your Medicare Part B monthly premium (currently $104.90 for 2015). Click here to download an application or you can have an application mailed to you by requesting it from your local County Assistance Office (1-877-395-8930).

Prescription Drug Assistance

  • Do you have Medicare?  Is your income below $17,235 (individual)/$23,265 (married)?  Are your assets (savings, stocks, bonds, etc) below $13,300 (individual)/$26,580 (married)? If "yes" to all 3 questions, you may qualify for the Low Income Subsidy/Extra Help Program.

Low Income Subsidy (LIS)/Extra Help Program:(Administered by the Social Security Administration. Click here to go to the online application.) This program helps Medicare beneficiaries to lower their prescription drug costs.

  • Are you 65 years of age or older? Is your income below $23,500 (individual)/$31,500 (married)? You may qualify for the PACE/PACENET program.  Click here for more information. To apply online, click here. This program is for older adults (65 years or older) to help lower the co-pays for prescription drugs.

  • Do you have Schizophrenia and need assistance accessing your medications?  Click here


  • Do you have HIV/AIDS and need assistance accessing your medications and/or certain lab services? Click here

You may qualify for the Special Pharmaceutical Benefits Program (see below) even if you have Medicare, employer health insurance or Medical Assistance (if there is no prescription drug coverage).

Special Pharmaceutical Benefits Program-provides assistance with medication access for individuals with Schizophrenia or HIV/AIDS.

For more information on both programs: click here

*NOTE: Individuals with Medical Assistance ("Medicaid") may be eligible for the State Pharmaceutical Benefits Program (SPBP) IF their current coverage does NOT include prescription drugs*


SPBP 1: HIV/AIDS (click on link to download application)

Income up to: $55,000 for an individual

Must have proof (diagnosis by physician) of HIV/AIDS (see application for more details)

Covers the co-pays for medications used to treat HIV/AIDS.

If you have Medicare, will cover the cost of your Medicare Part D (Prescription drug plan) premium.


SPBP 2: Mental Health (Schizophrenia) (click on link to download application)

Income up to: $35,000 for an individual.

Must have proof (diagnosis by physician) of Schizophrenia (see application for more details).

The following atypical antipsychotics listed below are the only medications covered by the SPBP 2 (Mental Health) program.










For eligible individuals, there are no co-pays for medications used to treat Schizophrenia.

Also covered by the SPBP 2 program-Clozaril Support Services offered by:

  • Physicians
  • Outpatient Psychiatric Clinics
  • Psychiatric Partial Hospitalization Clinics

 3544 North Progress Avenue, Suite 107 |  Harrisburg, PA 17110  |  717-857-3163Click here to go to the National Suicide Prevention Lifeline website

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