Form Il-1363 - Application For Circuit Breaker Grant, License Plate Discount, And Optional Help Paying For Drugs (Pharmaceutical Assistance Or Seniorcare) - 2004
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20Illinois Department on Aging
2004
IL-1363 Instructions and Benefits Information
Application for Circuit Breaker grant, license plate discount, and optional help
paying for drugs (Pharmaceutical Assistance or SeniorCare)
Seniors and persons with disabilities may
requirements for age, residency, and income. See
qualify for benefits by filing Form IL-1363, Application
Page 2, “Who should apply?” for more information.
for Circuit Breaker grant, license plate discount and
Form IL-1363 must be postmarked by
optional help paying for drugs (Pharmaceutical
December 31, 2005. File earlier to get your benefits
Assistance or SeniorCare), if they meet
sooner.
What benefits are available?
Help paying for drugs
Circuit Breaker grant
You may ask for help paying for drugs for you, your
You may get a Circuit Breaker grant if you paid
spouse, or your qualified additional resident. Qualified
property tax or mobile home tax on your home - even
applicants may get either SeniorCare or Circuit
if you rent or live in a nursing home.
Breaker Pharmaceutical Assistance drug
coverage through June 2006.
License plate discount
1) Some lower-income seniors who apply will qualify
If we approve your application, the Illinois Secretary
for SeniorCare drug coverage. Those who get a
of State’s office will allow you a license plate fee
SeniorCare drug coverage card may exchange it
discount on your vehicle.
for a $25 monthly rebate if they have private
insurance that pays for drugs.
2) All other applicants may get Circuit Breaker
Are there any new benefits?
Pharmaceutical Assistance with Illinois Rx Buying
You may use your Pharmaceutical
Club discounts.
Assistance card to obtain Illinois
To apply or reapply for help paying for drugs, you
Rx Buying Club discounts on drugs
must tell us on your application. Don’t forget to
not covered by Pharmaceutical Assistance.
check the box!
Table of Contents
What benefits are available? ...................... 1
Line-by-line instructions
Includes information on what is new for this year.
for Form IL-1363 ........................................ 10
Note: Lines 5 and 12 instructions (to apply for help
Who should apply? ..................................... 2
paying for drugs) are on Pages 11 and 12.
Provides information on eligibility.
You may need to attach ............................ 17
How do I apply? ........................................... 3
Describes the information you may need to attach
to help avoid delays in receiving your benefits.
Confidentiality and privacy information ........ 3
You may want to visit a local office ......... 19
Questions about benefits
Where may I get help or more forms? .... 20
4
Circuit Breaker grant .......................................
4
How to estimate your grant..............................
Illinois Rx Buying Club information ........ 20
5
License plate discount ........................................
6
Help paying for drugs ......................................
........7
SeniorCare requirements for noncitizens
...............8
Form IL-1363 drug programs chart
. ................................ 10
SeniorCare rebate
1
Apply every year
Renew by March 31
IL-1363 instructions (R-12/04)
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