Looking for a Illinois Tax Forms And Templates? Download it for free!

Form Il-1363 - Application For Circuit Breaker Grant, License Plate Discount, And Optional Help Paying For Drugs (Pharmaceutical Assistance Or Seniorcare) - 2004 Page 8

Form IL-1363 drug programs chart

Program name

You may qualify if:

Program covers:

You are an Illinois resident who…

The Pharmaceutical

Circuit Breaker

Assistance card covers

is age 65 or older; or

Pharmaceutical

prescriptions for…

is a recent widow or widower age 63 or

Assistance

Alzheimer’s disease

64 (if your spouse was receiving or

Program

was eligible to receive Form IL-1363

Arthritis

benefits); or

(with Illinois Rx Buying

Cancer (Some

is age 16 years of age or older before

prescriptions may

Club Discounts)

January 1, 2005, and totally disabled;

require prior approval.)

and

Diabetes (This

includes insulin,

You have a total annual income of…

syringes, and

less than $21,218 for a single-person

needles.)

household; or

Glaucoma

less than $28,480 and are married and

Heart and blood

live with your spouse or one qualifying

pressure problems

resident; or

Lung disease and

less than $35,740 if filing an

smoking-related

application for yourself, your spouse

illnesses

and at least one qualified additional

Multiple sclerosis

resident, or yourself and at least two

qualified additional residents.

Osteoporosis

Parkinson’s disease

You do not qualify for SeniorCare.

All prescription drugs

Illinois Rx

Note:You are automatically enrolled in the

approved by the FDA and

Buying Club

Illinois Rx Buying Club when you are

available through…

information

enrolled in Circuit Breaker

Participating

Pharmaceutical Assistance.

pharmacies; and

The program’s mail-

order option (offering

a 90-day supply at

greater savings).

You are an Illinois resident who is age 65

The SeniorCare card covers...

Illinois

or older;

Most prescription drugs

SeniorCare

(some prescriptions

You have a total annual income of…

Program

require prior approval);

no more than $18,620* and you are

and

single; or

no more than $24,980* between both

Some over-the-counter

you and your spouse; and

drugs if a doctor

prescribes them:

You are a U.S. citizen or a qualified non-

analgesics

citizen. (If you do not complete this

antacids

information on the application, you may

* Income

laxatives

still be eligible for Circuit Breaker

amounts may

Pharmaceutical Assistance Program.)

smoking cessation

change in

aids

February 2005.

stool softeners

Apply every year

Renew by March 31

IL-1363 instructions (R-12/04)

Form Il-1363 - Application For Circuit Breaker Grant, License Plate Discount, And Optional Help Paying For Drugs (Pharmaceutical Assistance Or Seniorcare) - 2004 Page 8

Related Articles

Related forms

Related Categories