Complete initial eligibility screen


Welcome to the St. Vincent de Paul Community Pharmacy!

We are a Catholic, not-for-profit organization that is dedicated to helping the people in South Mississippi who cannot afford their prescription medicine because of no/not enough insurance.

In order to qualify for the program, you must show that you cannot afford your medicine.

This appointment is to determine if you qualify. Please bring all of the necessary papers to prevent any
delay in assistance. A list is on the back of this sheet.

If you do not have all your paperwork, your interview will be rescheduled.

Failure to come to your appointment may delay getting your medication.
 

What do I bring with me for my appointment?

1. A form of identification (preferably a photo ID)
2. Proof of Income This is required for all household members. You can bring in any of the following:

A. Current bank statements
B. Pay stubs for the entire month
C. Benefits letter from SSI or Social Security
D. All statements from any savings, IRA’s, CDs, annuities
E. A letter from anyone providing you income—signed and dated.

 What if I have no income? If you do not have income and are living with family or a friend who is providing you with shelter and food, please bring a signed, dated letter to that effect. If you have your own place to live but someone pays your bills, bring a letter from that person.

3. Proof of Expenses. The Pharmacy requires documentation for all bills you paid the previous month. If you pay a bill annually, the annual amount will be divided by 12. The document must include the date, amount paid and to whom it was paid. The Pharmacy will not count expenses that do not have documentation. Types of bills we are looking for include:

Utilities (electric, gas, water) Medical bills
Mortgage payments or rent

Car payment Medical insurance Credit card bills

Car insurance Home insurance Taxes

The Pharmacy provides an allowance for food, basic cable and basic phone service. No receipts are needed for these expenses.
4. Proof of Insurance if you have it and proof that you are using it but it does not provide you with enough coverage.

A. If you have Medicaid: bring a printout from your pharmacy showing the five medicines you obtained the previous month with that insurance. The pharmacy will only help with medicines other than the five you get with Medicaid.

B. If you have Medicare Parts A & B, please bring your card.

C. If you have Medicare Part D (a drug plan), you must bring your card, your insurance booklet showing your coverage and the formulary (list of medicines your plan covers). If you have Part D, the pharmacy will only help on a shared basis.

D. Private Insurance. Please bring your card and insurance booklet as explained in C.

E. If applying when you reach “the gap” for Part D, please bring your insurance letter informing you that you have reached or about to reach that gap in coverage as well as your Part D insurance booklet.

5. Written prescriptions if not already on file. The pharmacy requires written, paper prescriptions (or faxed prescriptions directly from your doctor’s office to the pharmacy). The SVdP Pharmacy is not licensed to dispense controlled medicines and cannot accept pill bottles or transfers from other drug stores.