Call the DC Pharmacy Benefits Hotline if you have questions: (202) 671-4815
Proof of Residency
Proof of District of Columbia residency is required. Residency can be documented with a copy of ONE of the following (showing your name and address):
- Current lease or mortgage statement, or deed settlement agreement
- Current driver’s license
- Current voter registration card
- Current Notice of Decision from Medicaid
- Fuel/utility bill (past 90 days)
- Property tax bill or statement (past 60 days)
- Rent receipt (past 90 days)
- Pay stubs or bank statement with your name and address (past 30 days)
- Letter from another government agency addressed to applicant
- Active (unexpired) homeowner’s or renter’s insurance policy
- DC Healthcare Alliance Proof of DC Residency form
- If homeless, please provide statement from case manager on facility letterhead
If you have a PO Box where you receive your mail you must include information documenting your physical address to document District of Columbia residency.
If you live with someone and have none of the items above in your name, we will need proof of their residency and a letter stating that you live with them:
Medical Verification
Your physician is required to complete and sign DC Pharmacy Benefits Medical Eligibility form verifying your HIV/AIDS status.
All Information is confidential.
Insurance Coverage
Premium Program Requirements
DC Pharmacy Benefits will only pay for applicant’s premium, not the premium for any of his or her family members. No payments will be made to the client directly; all payments will be made to the insurance company or employer. If Pharmacy Benefits is paying a client’s premium to his or her employer (as part of a group plan), ADAP will only pay the employee’s portion – not the entire premium. Premiums are paid on a monthly basis
Insurance Co-payment and Deductible Program Requirements
Coverage for all co-payments and deductibles are exclusively available for drugs on the DC ADAP formulary. Clients must utilize the DC Network pharmacies for coverage of co-payments and deductibles. Co-payments and/or deductibles cannot exceed monthly and annual cost units required by the DC ADAP program.
Proof of Income
Proof of income is required. Financial eligibility is based on 500% of the Federal Poverty Level (FPL): FPL varies based on household size and is updated annually. Financial eligibility is calculated on the gross income available to the household. See chart below.
|
Size of Family |
Monthly Allowable Income (Gross) |
Annual Income (Gross) |
|---|---|---|
|
1 |
$6,275.00 |
$75,300.00 |
|
2 |
$8,516.67 |
$102,200.00 |
|
3 |
$10,758.33 |
$129,100.00 |
|
4 |
$13,000.00 |
$156,000.00 |
|
5 |
$15,241.67 |
$182,900.00 |
|
6 |
$17, 483.33 |
$209,800.00 |
|
7 |
$19,725.00 |
$236,700.00 |
|
8 |
$21,966.67 |
$263,600.00 |
For Wage Earners
Income should be documented by copies of pay stubs for the past 30 days. The paystub must show the year-to-date earnings, hours worked, all deductions and the dates covered by the paystub. If you cannot get a paystub, send us a notarized letter from your employer showing gross pay for the past 30 days along with a copy of your most recent income tax return. (The letter does not need to be addressed to the Programs. A letter addressed “to whom it may concern” is sufficient.)
Self-employed Individuals
Provide business records for the three months prior to application indicating type of business, gross income, net income, and your most recent year income tax return. A notarized statement from you of projected current annual income must also be included.
Rental Income
Income you receive from rental property can be documented by a copy of the lease you have with your tenants and a copy of your most recent income tax return.
All Other Income
Copies of SSD/SSI award letters, unemployment checks, Social Security checks, pension checks, etc. from the past 30 days should be sent as proof of other types of income. If living off savings please provide a copy of bank statements, stocks, bonds, 401k, IRA etc.
No Income, Supported by Others
If you have no income and are supported by a friend or family member provide a letter from that friend or family member stating how they support you.
Household
Household members must be provided if applicable. Household members are only those individuals you are responsible for financially.
Recertification for DC Pharmacy Benefits is required every six months after open enrollment. Click Here.