Instructions And Benefits Information For Form Il-1363 - Illinois Department Of Revenue - 2002 Page 9
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20Prescription coverage guide
Part 2
Pharmaceutical Assistance
Do not send any
payment with your
Annual fee
$5 or $25 based on income
application. See
Co-payment
Page 7.
for a generic drug
$0 or $3 based on income
for a brand name drug
$0 or $3 based on income, plus the difference in
price between the brand name and generic drug*
Additional co-payment
an additional 20 percent of the cost of the drug
once Pharmaceutical Assistance has paid $2,000
for you (from July 2003 through June 2004)
Drugs covered
prescription drugs used for the treatment of:
Alzheimer’s disease
Arthritis
Cancer
Diabetes (including insulin and the syringes and
needles used to administer insulin)
Glaucoma
Heart and blood pressure problems
Lung disease and smoking-related illnesses
Osteoporosis
Parkinson’s disease
SeniorCare
Annual fee
There is no annual fee.
Co-payment
for a generic drug
$0 or $1 based on income
for a brand name drug
if generic is available
$0 or $4 based on income, plus the difference in
price between the brand name and generic drug*
if no generic is available
$0 or $4 based on income
Additional co-payment
an additional 20 percent of the cost of the drug once
SeniorCare has paid $1,750 for you (from July 2003
through June 2004)
Drugs covered
prescription drugs in the same categories as
Pharmaceutical Assistance
most other prescription drugs
over-the-counter drugs prescribed by your doctor
in these categories: analgesics, antacids,
laxatives, stool softeners, and smoking cessation
products
*
When a generic drug is available, but you choose to purchase a name brand drug, you must pay the difference in
price between the name brand and the generic drug unless the name brand drug is a federally defined narrow
therapeutic index drug and substitution is not permitted because your doctor has indicated “brand medically
necessary” on your prescription. This charge is in addition to your co-payment.
9
Avoid a delay
Apply by March 31
IL-1363 instructions (R-12/02)
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