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What are the additional costs after I pay

confirming renewal of coverage are mailed about seven

days before your current coverage is scheduled to

for my coverage?

expire.

Each month when you purchase your medicine, you will

Can I get a refund if I choose not to use

pay the pharmacist the first $15 or $25 of your drug cost.

The money you pay the pharmacist is called a

my coverage?

“deductible.” The amount of your deductible will be

Once you have used your coverage, you may not

based upon the cost of your coverage.

receive a refund. However, if you do not use your

Your monthly deductible will be $15 if the cost of

coverage, you may send us a written request for a

your coverage is $40.

refund.

Your monthly deductible will be $25 if the cost of

What if my Pharmaceutical Assistance

your coverage is $80.

card is lost or stolen?

After you have paid your monthly deductible, the

program will pay the rest until the accumulated total paid

If your card is lost or stolen and you wish to receive a

by the program (the drug cost plus the dispensing fee of

replacement card, you should notify the Pharmaceutical

$3.60 per prescription) reaches $800 for the fiscal year

Assistance Section at the address or telephone numbers

(July 1 - June 30). Then, in addition to your monthly

below.

deductible, you must also pay the pharmacist 20 percent

PHARMACEUTICAL ASSISTANCE PROGRAM

of the remaining cost for each prescription.

ILLINOIS DEPARTMENT OF REVENUE

PO BOX 19021

When a generic drug is available but you

SPRINGFIELD IL 62794-9021

choose to purchase a brand name drug, you must

1 800 624-2459

pay the difference in price between the generic and

the brand name drug. This charge is in addition to

1 800 544-5304 TDD (telecommunications device for the deaf)

your deductible.

What other features does the program

How can I benefit most from this

offer?

program?

The Pharmaceutical Assistance program includes a drug

Ask your doctor if he or she can prescribe a

review service. This service will work with your

generic drug for you. Generic drugs are usually

pharmacist and doctor to monitor and evaluate your

less expensive than brand name drugs.

prescriptions under this program. If your pharmacist has

Ask your doctor to prescribe your medicine in

a concern about your medication, he or she may call

monthly supplies (for as many as 34 days).

your doctor to discuss your medication. You may benefit

Many Illinois pharmacies participate in this

from this service especially when more than one doctor

program. Check with your pharmacist to make sure

is prescribing medications for you.

your coverage will be honored. Then use only one

Another feature the program offers is the use of a list of

pharmacy.

approved drugs called a formulary. Your pharmacist

Does participating in this program affect

and doctor may use this list to provide you with the most

effective medicine at the best price.

my benefits under other medical

insurance?

To participate in this program, you must assign to the

Pharmaceutical Assistance program any prescription

drug benefits you might otherwise be entitled to from

other insurance plans.

If you are enrolled in any public assistance program that

in any way covers an eligible drug, you may not use the

Pharmaceutical Assistance program for any such drug.

When can I expect to receive my

Pharmaceutical Assistance coverage?

A Circuit Breaker claim form must be filed and approved

each year before Pharmaceutical Assistance coverage

will be issued. If you are applying for Pharmaceutical

Assistance for the first time, you should receive

confirmation of your coverage by mail eight to 10 weeks

after your Circuit Breaker claim has been approved and

your coverage has been paid in full. Coverage always

becomes effective on the first day of the month. Cards

Page 4 of 12

IL-1363 instructions (R-12/99)

Form Il-1363 Instructions - Circuit Breaker And Pharmaceutical Assistance - Illinois Department Of Revenue Page 4

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