Form Il-1363 - Application For Circuit Breaker

Step 7: For your spouse’s prescription drug benefits only.

If you are married and living together, you must complete the following information about your spouse if your

spouse wants help paying for prescription drugs.

Is your spouse a

U.S. citizen or

qualified noncitizen?

Your spouse may still get some drug coverage even if no box is checked above.

If no, go to

Is your spouse eligible for Medicare for hospital or doctor expenses? yes

Line 37.

a If “yes,” has your spouse applied for prescription benefits with a Medicare Part D

Prescription Drug Plan?

yes

b If your spouse has applied for a Medicare Part D Prescription Drug Plan, what is the name of

your spouse’s plan?

United AARP MedicareRx

OSF Health Plans

PacifiCare Saver Plan

WellCare

Health Alliance

Other:

______________________________

c Has your spouse applied for “extra help” available under Medicare Part D? yes

If your spouse qualifies for the Illinois Cares Rx benefit and your spouse has other health insurance

that pays for prescription drugs, your spouse can choose to receive a $25 monthly rebate instead of

receiving help paying for prescriptions.

If no,

a Does your spouse have other health insurance that pays for prescription drugs? yes

go to

Step 8.

b If “yes,” does your spouse want to receive the $25 monthly rebate instead of receiving

help paying for prescriptions? yes

Step 8: Complete the following information only if you or your spouse are

eligible for Medicare for your hospital or doctor expenses.

Enter the total amount of bank accounts, investments or cash that either you, your spouse (if married and

living together) or both of you own, in the boxes below. Include items that either of you own with another

person. If you or your spouse do not own an item listed, place zeroes in the space provided.

a Bank Accounts (checking, savings and certificates of deposit) ................................ a

b Stocks, bonds, savings bonds, mutual funds, individual retirement accounts

and similar investments .............................................................................................. b

c Any other cash at home or elsewhere ....................................................................... c

Add Lines 38a through 38c. This is your total.

If you are single and the total amount on Line 38d is $11,500 or less, you must complete

Schedule C. If the total amount on Line 38d is greater than $11,500, you do not need to

complete Schedule C.

If you are married and living together and the total amount on Line 38d is $23,000 or less, you must

complete Schedule C for you and your spouse. If the total amount on Line 38d is greater than $23,000,

you and your spouse do not need to complete Schedule C.

IL-1363 3 of 4(R-12/05)

Form Il-1363 - Application For Circuit Breaker - 2005 Page 3

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