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  Home >> Eligiblity Policy and Oversight >> Download Applications

 Application Download Page
 Checklist for Required Documentation
 Income Limits for the Specific Program


The information below is based on the selected need for coverage made on a previous page.

This page will provide you with:

  • An Application
  • A Checklist Of Required Documentation
  • Income Limits (if applicable)
For the Medicaid program or other coverage programs managed by DHHS.

Note: Coverage is provided under many categories with different income limits. More than one income table may be presented (if applicable). Not all programs providing coverage are Medicaid programs.

Gap Assistance Pharmacy Program For Seniors (GAPS)
GAPS is not a Medicaid program.
It is a state-funded program administered by the Department of Health and Human Services.

200% Of Poverty Level
February 24, 2009
Family Size Monthly Income Annual Income
1 $1,805 $21,660
2 $2,429 $29,140
3 $3,052 $36,620
4 $3,675 $44,100
5 $4,299 $51,580
6 $4,922 $59,060
7 $5,545 $66,540
8 $6,169 $74,020
Each additional member $624 $7,480
For each additional family member, add $7,480 to the annual income. Divide by 12 and round up to the next whole dollar for the monthly income.



Printable Applications
Applications in Adobe PDF Format Form Link Description
FM 942 « GAPS Application

What else you will need.
Check List for FM 942
Then Mail Applications to: ¬
(FM 942) Mail to Central Eligiblity Office



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