How to Fill Out and Submit the PACENET Application Form

To apply for PACENET, complete the joint PACE/PACENET application using your gross income from the previous calendar year and submit it online, by mail, by fax, by email, or by phone through the PACE Application Center at 1-800-225-7223. It is one form for both programs. The state reviews your income and places you in whichever tier fits, so you do not have to decide between PACE and PACENET yourself.

Who Qualifies for PACENET

Three requirements decide eligibility: age, residency, and income. You must be at least 65, have lived in Pennsylvania for at least 90 days before applying, and have prior-year income within the program’s range.1Commonwealth of Pennsylvania. Apply for the Pharmaceutical Assistance Contract for the Elderly Program You cannot be receiving prescription drug benefits through Medical Assistance, Pennsylvania’s Medicaid program.2Pennsylvania House of Representatives Appropriations Committee. Senior’s Pharmaceutical Assistance Programs

PACENET is the upper income tier. Standard PACE covers single applicants with total annual income between $14,501 and $33,500, and married couples between $17,701 and $41,500.1Commonwealth of Pennsylvania. Apply for the Pharmaceutical Assistance Contract for the Elderly Program If your income exceeds those PACE ceilings, you fall into the PACENET tier. The PACENET upper limits are adjusted periodically, so confirm current figures with the PACE Application Center at 1-800-225-7223 or at pacecares.primetherapeutics.com before assuming you are over or under.

What Counts as Income

The program uses gross income from the previous calendar year, not your current monthly earnings. Included: Social Security and SSI (gross, before the Medicare premium deduction), railroad retirement, all pensions, wages, self-employment earnings, interest, dividends, capital gains, unemployment, workers’ compensation, alimony, and gambling winnings. Cash gifts and inheritances count only above $300, and death benefit payments only above $10,000. If you are married and living together, your spouse’s income is included.3PACEcares. PACE Income Eligibility

Not counted: Property Tax/Rent Rebates, VA Aid and Attendance, SNAP, LIHEAP, Black or White Lung benefits, civil lawsuit damages or settlements, federal stimulus payments, VA dependency and indemnity compensation, and income from other people living in your household besides your spouse.3PACEcares. PACE Income Eligibility

What to Gather Before You Start

Have these ready. Missing information is the fastest way to slow your review down.

  • Social Security numbers for you and, if married, your spouse.
  • Your Pennsylvania driver’s license or photo ID number. The form has a specific field for it; a birth certificate is not required on the application itself.4PACE. PACENET Application Form
  • Previous year’s income records: Social Security 1099s, RRB-1099 and RRB-1099R for railroad retirement, SERS and PSERS pension statements (the form lists these separately), other pension and annuity statements, 401(k) and IRA distribution records, and any documentation of wages, self-employment, rental income, interest, dividends, or capital gains.
  • Medicare Part D plan name and ID number, if you are enrolled in one.

Filling Out the Form

Begin with the personal information section: name, address, date of birth, Social Security number, and PA driver’s license or photo ID number. A married applicant fills in a parallel set of fields for the spouse. Check the Social Security numbers carefully; a single wrong digit can stall the review.

The income section is where most of the work happens. The form breaks income into six numbered categories, each with a separate box for applicant and spouse:4PACE. PACENET Application Form

  • Line 1: gross Social Security and SSI.
  • Line 2: railroad retirement, from RRB-1099 and RRB-1099R.
  • Lines 3a and 3b: Pennsylvania SERS and PSERS pensions, listed separately.
  • Line 4: all other pensions, plus the taxable amounts of annuities, 401(k) distributions, and IRAs not already reported on 3a or 3b.
  • Line 5: interest, dividends, capital gains, and prizes.
  • Line 6: everything else, including wages, self-employment income, rental and business income, cash public assistance, unemployment, workers’ compensation, alimony, gambling winnings, gifts and inheritance over $300, death benefits over $10,000, and royalties.

Report gross amounts, not net. The most common mistake is entering the Social Security amount deposited to your bank each month, which is already reduced by the Medicare premium. Use the gross figure from the 1099 instead.

The form also asks about your current prescription drug coverage. If you have Medicare Part D or any other insurance that pays for medications, list the carrier name and policy number so benefits can be coordinated.

Read the certification statement before signing. Your signature confirms the age and income information is true and complete. Both spouses must sign a married-couple application.

How to Submit It

Four channels are available:

You can also call the PACE Application Center at 1-800-225-7223 for help completing and submitting the form by phone.5PACEcares. Contact PACE Local Area Agencies on Aging can walk you through it in person.

What Happens After You Submit

Expect a written response within about 30 days. If you are approved, a PACENET card arrives in the mail. Show it at the pharmacy to access your benefits.

If you are denied, the letter will explain why. The usual reason is income falling outside the eligible range: too high for PACENET, or low enough that you should be in PACE or possibly Medical Assistance instead. If you believe the determination is wrong, call the PACE Application Center at 1-800-225-7223.5PACEcares. Contact PACE

What PACENET Costs After You Are Approved

PACENET is not free. For plan year 2026, the monthly premium is $32.71, and it is collected at the pharmacy rather than billed separately. The first dollars you spend on prescriptions each month go toward that month’s premium; once the $32.71 is paid, your remaining fills that month cost only the copay.6PACEcares. Frequently Asked Questions

Copayments are $8 for a 30-day supply of a generic drug and $15 for a 30-day supply of a brand-name drug.7York County, PA. PACE and PACENET You never pay more than the actual cost of the medication in a single transaction. If you do not use your card in a given month, no premium is collected, and it does not roll over.6PACEcares. Frequently Asked Questions

PACENET cardholders are enrolled in one of the program’s partner Medicare Part D plans, currently SilverScript Choice or Wellcare Classic. The Part D plan pays first, and PACENET covers the remainder at the copay rates above.6PACEcares. Frequently Asked Questions That is why the coverage question on the application matters: accurate answers keep the two layers coordinated.

Renewing Each Year

Your card is valid only for the period printed on the front. About two months before it expires, the program mails you a renewal application automatically. You do not have to resubmit proof of age or residency. Eligibility is reviewed each year against the previous calendar year’s income, so keep your income records organized. If your income changes, you may be shifted to the standard PACE tier or, if it rises above the cap, lose eligibility.