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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

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

you must live in Illinois at the time you file the

claim; and

Assistance coverage cost?

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

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

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

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