Form Il-1363 - Application For Circuit Breaker / Illinois Cares Rx / License Plate Discount - 2008 Page 3

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(Section F continued.)
32
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 (VA) benefits, or a non-coordinating
Medicare Part D plan that pays for prescription drugs? yes
no
f “no,” go to Section G.)
(I
b 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 listed in Line 31b. If you are enrolled in one of these plans, Illinois Cares Rx will help
pay for your prescriptions.
G
:
SECTION
For your spouse’s Illinois Cares Rx benefits or monthly rebate.
See instructions.
33
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.
34
Is your spouse currently eligible for Medicare Part A and/or Part B for his or her hospital or doctor expenses?
yes
no
f “no,” go to Line 35.)
(I
a If “yes,” print the name and claim number as it appears on your spouse’s red, white and blue Medicare card or
Railroad Retirement card.
________________________________________________
First name
Last name
Claim number
b 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
Group Health Plan (GHP)
SecureHorizons
1
6
11
by United Healthcare
Essence
Health Alliance
2
7
Medical Plans
Erickson
SilverScript
3
12
Evercare
HealthSpring
UnitedHealth Rx Basic
4
8
13
First Health Part D
Humana
WellCare Classic
5
9
14
— Premier
PersonalCare
Other: __________________
10
15
c Does your spouse have HIV/AIDS? yes
no
See instructions for added "wrap around" benefits.
35
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 (VA) benefits, or
a non-coordinating Medicare Part D plan that pays for prescription drugs? yes
no
(If “no,” go to Section H.)
b Does your spouse want a $25 monthly rebate instead of help paying for prescriptions? yes
no
Do not mark "yes" if your spouse is receiving prescriptions through a coordinating Medicare Part D plan
listed in Line 34b. If your spouse is enrolled in one of these plans, Illinois Cares Rx will help pay
for his or her prescriptions.
IL-1363 3 of 4 (R-12/08)
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