Form Adad-16 - Application For Illinois Cares Rx
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Illinois Department on Aging
Clerk ID
Application for Illinois Cares Rx
After Form IL-1363 has been filed in a claim year
Official use only
Complete this application only if you want help paying for drugs or a monthly rebate and did not make this request on
your previously filed 2007 Form IL-1363, Application for Circuit Breaker and Illinois Cares Rx.
Step 1: Claimant Information.
1
Social Security number
2
Name
________________________________________________________________________________
First
M I
Last
3
Address
________________________________________________________ Apt._________________
City
____________________________________________
State
________
ZIP_________________
4
Are you
Male
Female
5
If no, go to Step 2.
a
Yes, I want help paying for drugs or a monthly rebate.
b Are you a
U.S. citizen or
qualified noncitizen?
See instructions.
You may still qualify for drug coverage if no box is checked in Line 5b.
6
Are you eligible for Medicare Part A and/or Part B for your hospital or doctor expenses?
yes
no
If no, go to Line 7.
a
If you are already enrolled in a Medicare Part D plan, what is the name of your plan?
AARP Medicare Rx Preferred
Health Alliance Medical Plans
SilverScript
1
7
13
Essence
HealthSpring
UnitedHealth Rx Basic
2
8
14
Erickson
Humana
WellCare
3
9
15
Evercare
OSF HealthPlans
Other: _________________
4
10
16
First Health Part D – Premier
PersonalCare
5
11
Group Health Plan (GHP)
SecureHorizons by United Healthcare
6
12
b
Have you applied with Social Security for “extra help” under Medicare Part D? yes
no
c
See instructions for added “wrap around” benefits.
Do you have HIV/AIDS? yes
no
d
Print the name and claim number as it appears on your Medicare card or Railroad Retirement card.
____________________________________________
First Name
Last name
Claim number
7
You can choose to receive a $25 monthly rebate instead of help paying for prescriptions.
a
Do you have private, creditable health insurance, Veterans Administration benefits, or a non-coordinating
Medicare Part D plan that pays for prescription drugs? yes
no
If no, go to Step 2.
b
Can you enroll in Medicare Part D without losing your private, creditable health insurance? yes
no
c
Do you want a $25 monthly rebate instead of help paying for prescriptions? yes
no
Do not mark "yes" if you are receiving prescriptions through a coordinating Medicare Part D plan
and need “wrap around” benefits under Illinois Cares Rx.
IISG08-121
This form is authorized as outlined by the Senior Citizens and Disabled Persons Property Tax Relief and Pharmaceutical Assistance Act.
ADAD-16 (R-4/08)
1 of 4
Disclosure of this information is REQUIRED. Failure to provide information could delay your grant and/or prescription coverage.
IL-402-2019
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