Form Il-1363 - Application For Circuit Breaker Grant, License Plate Discount, And Optional Help Paying For Drugs (Pharmaceutical Assistance Or Seniorcare) - 2004 Page 9
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20Form IL-1363 drug programs chart
How program works:
Circuit Breaker Pharmaceutical Assistance (continued from Page 8)
If your application is approved, you receive a Circuit Breaker Pharmaceutical Assistance card.
Cards cost…
$5 if your income is below the federal poverty level; or
$25 if your income is at or above the federal poverty level.
With that card, you can obtain prescription medication for covered diseases with…
No co-payment if you have the $5 card; or
A $3 co-payment if you have the $25 card.
(Note: For brand name drugs when a generic is available, you will also be required to pay the
difference in price.)
After Circuit Breaker Pharmaceutical Assistance pays $2,000 per person in benefits,
you must pay your co-payment plus 20 percent of cost for each prescription for the
remainder of the fiscal year (July 1 - June 30).
You will automatically be enrolled in the Illinois Rx Buying Club for no additional fee. The
Circuit Breaker Pharmaceutical Assistance card will work for both programs.
Illinois Rx Buying Club (continued from Page 8)
For prescriptions not covered by Circuit Breaker Pharmaceutical Assistance, present
your card at any participating pharmacy for immediate savings. No further forms to fill
out nor coupons required.
You may expect an average 20 percent discount on prescriptions that you fill.
You will also receive information about how to use the mail-order option.
There is no annual cap and no limit to the savings.
SeniorCare (continued from Page 8)
There is no annual enrollment fee. If your application is approved, you receive a
SeniorCare card.
If you are…
Note: For brand
Single with an income of no more than $9,309* a year; or
name drugs
when a generic is
A couple who have an income of no more than $12,489* a year…
available, you will
SeniorCare will pay up to $1,750 per person in a fiscal year at no cost. After
also be required
that, participants pay 20 percent of the cost of each prescription.
to pay the
If you are…
difference in
Single with an income between $9,310* and $18,620* a year; or
price.
A couple who have an income between $12,490* and $24,980* a year…
Each participant pays $1 for each generic and $4 for each brand name prescription.
After SeniorCare pays $1,750 per person in a fiscal year, you pay $1 for generic and
$4 per brand name prescription plus 20 percent of the cost for each prescription.
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Apply every year
Renew by March 31
IL-1363 instructions (R-12/04)
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