Form Il-1363 - Application For Circuit Breaker And Illinois Cares

Form Il-1363 - Application For Circuit Breaker And Illinois Cares - 2007 Page 3

(Step 6 continued.)

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

If “no,” go to Step 7.

b Can you enroll in Medicare Part D without losing your private, creditable health insurance? yes

c Do you want a $25 monthly rebate instead of help paying for prescriptions? yes

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.

Step 7: For your spouse’s prescription drug benefits or monthly rebate.

Is your spouse a

U.S. citizen or

qualified noncitizen?

See instructions for more information.

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

Is your spouse eligible for Medicare Part A and/or Part B for his or her hospital or doctor expenses? yes

If “no,” go to Line 37.

a If your spouse is already enrolled in a Medicare Part D plan, what is the name

of your spouse’s plan?

AARP Medicare Rx Preferred

Health Alliance Medical Plans

SilverScript

Essence

HealthSpring

UnitedHealth Rx Basic

Erickson

Humana

WellCare

Evercare

OSF HealthPlans

Other: __________________

First Health Part D – Premier

PersonalCare

Group Health Plan (GHP)

SecureHorizons by United Healthcare

b Has your spouse applied with Social Security for “extra help” under Medicare Part D? yes

c Does your spouse have HIV/AIDS? yes

See instructions for added "wrap around" benefits.

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

________________________________________________

First name

Last name

Claim number

Your spouse can choose to receive a $25 monthly rebate instead of help paying for prescriptions.

a Does your spouse have private, creditable health insurance, Veterans Administration benefits, or a non-

coordinating Medicare Part D plan that pays for prescription drugs? yes

If “no,” go to Step 8.

b Can your spouse enroll in Medicare Part D without losing his or her private, creditable health insurance?

yes

c Does your spouse want a $25 monthly rebate instead of help paying for prescriptions? yes

Do not mark "yes" if your spouse is receiving prescriptions through a coordinating Medicare

Part D plan and needs “wrap around” benefits under Illinois Cares Rx.

IL-1363 3 of 4 (R-12/07)

Go to Page 4

Form Il-1363 - Application For Circuit Breaker And Illinois Cares - 2007 Page 3

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