Form Adad-16 - Application For Illinois Cares Rx - Illinois Department On Aging

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Clerk ID

Illinois Department on Aging

Application for Illinois Cares Rx

Official use only

After Form IL-1363 has been filed in a claim year

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 2006 Form IL-1363, Application for Circuit Breaker and Illinois Cares Rx.

Step 1: Claimant Information.

Social Security number

Name ____________________________________________________________________

First

M I

Last

Address __________________________________________________ Apt. ___________

City __________________________________________ State _____ ZIP ___________

Are you

Male

Female

5 a

Yes, I want help paying for drugs or a monthly rebate.

If no, go to Step 2.

Are you a

U.S. citizen or

qualified noncitizen?

See instructions.

Note: You may still qualify for Illinois Cares Rx Basic if no box is checked in Line 5b.

yes

Are you eligible for Medicare for your hospital or doctor expenses?

If no, go to Line 7.

yes

If “yes,” are you enrolled in a Medicare Part D prescription drug plan?

b If you are enrolled in a Medicare Part D prescription drug plan, what is the name of your plan?

United AARP MedicareRx

Health Alliance

WellCare HMO

UnitedHealth Rx Basic

HealthSpring

Other: ________________________

WellCare Signature

OSF Health Plans

Group Health Plan (GHP)

SecureHorizons by United Healthcare

yes

Have you applied with Social Security for “extra help” under Medicare Part D?

yes

Do you have HIV/AIDS?

See instructions for new “wrap around” benefits.

Print the name and claim number as it appears on your Medicare card or Railroad Retirement card.

___________________________________________

First

Last name

Claim number

instead of

You can choose to receive a $25 monthly rebate

help paying for prescriptions.

Do you have private, creditable health insurance, Veterans Administration benefits, or a non-coordinating

yes

Medicare Part D plan that pays for prescription drugs?

If no, go to Step 2.

If you have private, creditable health insurance that pays for prescription drugs, can you enroll in Medicare

yes

Part D without a loss of coverage or benefits?

instead of

yes

Do you want a $25 monthly rebate

help paying for prescriptions?

Do not

"yes"

mark

if you are receiving prescriptions through a coordinating Medicare Part D plan

and need “wrap around” benefits under Illinois Cares Rx.

This form is authorized as outlined by the Senior Citizens and Disabled Persons Property Tax Relief and Pharmaceutical Assistance Act. Disclosure of this information

is REQUIRED. Failure to provide information could delay your prescription coverage. IL-402-2019

(R-3/07) ADAD-16,

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