Form Il-1363 - Application For Circuit Breaker Grant, License Plate Discount, And Optional Help Paying For Drugs (Pharmaceutical Assistance Or Seniorcare) - 2004 Page 10
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20Questions about the SeniorCare rebate
What is the SeniorCare rebate?
You must maintain your own health insurance
prescription coverage as long as you get the
The SeniorCare rebate is a $25 monthly check
SeniorCare rebate. If your prescription insurance
that you may choose to receive instead of the
ends for any reason, call us right away at
SeniorCare drug coverage if
1-800-226-0768 so we can stop your monthly
you have health insurance coverage that
rebate check and restart your SeniorCare drug
includes prescription drug coverage, and
coverage You can have either the SeniorCare
you qualify for SeniorCare drug coverage.
card or the rebate, but not both.
If you choose the SeniorCare rebate, you must
When will I begin to get the rebate
use your own health insurance to help pay for
check?
your prescriptions. The only SeniorCare benefit
you will get is the monthly rebate check.
Your first rebate check will be sent in
approximately six to eight weeks after your
How do I get the SeniorCare rebate
SeniorCare drug coverage card is cancelled.
for myself or my spouse?
First you must apply for SeniorCare drug
What if I want more information
coverage and be approved. To apply, complete
about SeniorCare?
Form IL-1363 and if you want SeniorCare for
For further information,
yourself, you must check the box on Line 5a
call:
and complete Line 5b, or
SeniorCare HealthBenefits Hotline
your spouse, you must check the box on
1 800 226-0768
Line 12a and complete Line 12b.
1 877 204-1012 (TTY)
When you are approved, you will get a
or visit:
SeniorCare card and a rebate form. Complete
the rebate form and return it to:
SENIORCARE
STATE OF ILLINOIS
PO BOX 19158
SPRINGFIELD IL 62794-9158
Line-by-line instructions for Form IL-1363
Step 1:
Tell us about yourself (claimant).
1 Social Security number
You must use the address where you live.
Write your Social Security number exactly as it
A change in your address can affect the amount of
appears on your Social Security card. If you do
your grant. Therefore, we cannot accept the
not have your own Social Security number, you
address of your Social Security representative
may apply for one at any Social Security
payee, your vacation area, a relative, a bank, your
Administration office. You must be assigned a
trustee, the person who holds your power of
Social Security number before you send us your
attorney, a conservator, or a post office box
Form IL-1363.
number.
2 Name
4 Phone number
Print your first name, middle initial, and last name.
Write the area code and phone number where we
can reach you during the day. It may be necessary
3 Address
to call you in order to complete the processing of
Print your street address and apartment number
your application.
(if you have one), your city, state, and ZIP code.
10
Apply every year
Renew by March 31
IL-1363 instructions (R-12/04)
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