Form Il-1363 Instructions - Circuit Breaker And Pharmaceutical Assistance - Illinois Department Of Revenue Page 3

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Can my husband or wife qualify for the
What is the Pharmaceutical
Pharmaceutical Assistance program?
Assistance program?
To qualify, he or she must
be living in the same household as you (the
The Pharmaceutical Assistance program is an optional
claimant); and
benefit program that helps you pay for approved
be 65 years of age or older before January 1, 2000,
prescription medications used for the treatment of
or totally disabled in 1999; and
heart and blood pressure problems;
mark “yes” in the Pharmaceutical Assistance
diabetes (and syringes and needles used to
section in Step 2, Line 11, on the front of the Circuit
administer insulin); and
Breaker claim form.
arthritis.
Your husband or wife must sign up for the
How do I know if my medicines qualify
Pharmaceutical Assistance program each year he or she
wishes to participate.
under the program?
If this is the first time your husband or wife is applying
You should check with a participating pharmacy to make
for Pharmaceutical Assistance and he or she is at least
sure your medicines qualify before applying for
65 years of age, he or she must send proof of his or her
Pharmaceutical Assistance.
date of birth. Examples of proof we will accept can be
How do I qualify for this program?
found on Page 5 of this booklet.
If your husband or wife is under age 65, he or she must
To qualify, you must meet the following requirements:
be totally disabled to qualify for Pharmaceutical
1
you must have been 65 years of age or older
Assistance; your husband or wife must send us proof of
before January 1, 2000; or
disability. Examples of proof we will accept can be found
you must have been 16 years of age or older
on Page 9 of this booklet.
before January 1, 2000, and totally disabled; or
Any husband or wife who qualifies for Pharmaceutical
you must be a widow or widower who turned 63
Assistance will receive coverage under his or her own
years of age before the deceased claimant’s
name and Social Security number.
death; and
How much does Pharmaceutical
2
you must live in Illinois at the time you file the
claim; and
Assistance coverage cost?
3
you and your husband or wife must have had a
The cost of Pharmaceutical Assistance coverage will be
total combined income of less than $16,000 in
based on your income.
1999; and
Your coverage will cost $40 if
4
you must file Form IL-1363, Circuit Breaker and
you are single and your total yearly Circuit Breaker
Pharmaceutical Assistance Claim, postmarked on
income is $8,240 or less; or
or before December 31, 2000, and mark “yes” in
you are married and living together and your total
Step 1, Line 7.
combined yearly Circuit Breaker income is $11,060
How do I apply?
or less.
Your coverage will cost $80 if
You may apply by marking “yes” in the Pharmaceutical
Assistance section in Step 1, Line 7, on the front of the
you are single and your total yearly Circuit Breaker
Circuit Breaker claim form.
income is greater than $8,240 and less than
$16,000; or
You must sign up for the Pharmaceutical Assistance
program each year you wish to participate.
you are married and living together and your total
combined yearly Circuit Breaker income is greater
How am I notified of my acceptance into
than $11,060 and less than $16,000.
the program?
We will deduct this fee from your Circuit Breaker grant if
you are eligible to receive one. If you are not eligible to
When you qualify for Pharmaceutical Assistance, we
receive a grant or if your grant is not sufficient to pay for
issue you a Pharmaceutical Assistance card, which
the cost of your coverage, we will bill you.
confirms your participation in the program and shows
your effective date of coverage. Your coverage will be
If you wish to pay for your coverage in
valid for one year from the date it is issued. It is not
advance, you may send us a check payable to
necessary to present your card at the pharmacy when
“Illinois Department of Revenue” in the amount of
you pick up your medications. If you do not present your
$80 for each individual requesting coverage. If you
card, however, you must provide your Social Security
overpay, we will refund you the difference.
number.
IL-1363 instructions (R-12/99)
Page 3 of 12

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Parent category: Financial