Circuit Breaker and Illinois Cares Rx Forms

There are several ways to apply:

• File on the Internet (see below)
• Print out the form, complete and mail it* (see below)
• Open and fill in the form, print it out and mail it* (see below)
• Contact us (see Contact Information)

Apply Online

Get your benefits FAST... file your application (Form IL-1363) on the Internet!

2011 IL-1363 Forms

The following forms are in a PDF format, which requires Adobe Acrobat Reader to view. To receive a larger quantity of the forms, contact the Senior HelpLine.

• IL-1363 Application Booklet:
  Pages 1 - 13 contains the IL-1363 application form as well as qualifications and benefits information.
  Pages 14 - 32 contains Schedule A, Schedule C, line-by-line instructions and contact information.




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• Individual forms and schedules:
  
  
  • IL-1363: Application for Illinois Cares Rx and Circuit Breaker (4 pages) plus Schedule C (4 pages: 2 form & 2 instructions) (total of 8 pages)
    1. Print out a blank copy of the form. Complete the form, make a copy for yourself and mail the original as directed on the form.
       or
    
    
    2. Fill in the form then print it. Print out at least 2 copies – one for yourself and one to mail as directed on the form.
  
  

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  • Schedule A: Physician's Statement (2 pages: 1 form & 1 instructions)
    You may need to ask your doctor to complete Schedule A if you were younger than 65 years of age on January 1, 2012, and you are the claimant, or you are the claimant’s spouse or QAR who is applying for help paying for drugs.
    1. Print out a blank copy of the form. Have your doctor complete the form, make a copy for yourself and mail the original as directed on the form.
  
  

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  • Schedule B: Qualified Additional Residents (2 pages: 1 form & 1 instructions)
    You need to complete Schedule B if you are also claiming a qualified additional resident – an individual, other than your spouse, 1) who lived with you in the same residence in 2011 and in 2012 at the time you file your 2011 Form IL-1363; and 2) for whom you, or you and your spouse, provided more than half of that person’s total financial support in 2011; and 3) who is not filing a separate 2011 Form IL-1363.
    1. Print out a blank copy of the form. Complete the form, make a copy for yourself and mail the original as directed on the form.
       or
    
    
    2. Fill in the form then print it. Print out at least 2 copies – one for yourself and one to mail as directed on the form.
  
  

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  • Schedule C: Pharmaceutical Benefits (4 pages: 2 form & 2 instructions)
    You may need to complete Schedule C if you, or your spouse, are Medicare-eligible and want help paying for your prescription drugs. Be sure to read the instructions for line 34 (Section H) on page 21 of the Form IL-1363 application booklet.
    1. Print out a blank copy of the form. Complete the form, make a copy for yourself and mail the original as directed on the form.
       or
    
    
    2. Fill in the form then print it. Print out at least 2 copies – one for yourself and one to mail as directed on the form.
  
  

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  • Schedule P: Projected Income Schedule for Illinois Cares Rx Drug Coverage (4 pages: 2 form & 2 instructions)
    You should file Schedule P if an event has occurred that has decreased your income to a qualifying level (see instructions) and you want to apply for the following reason: to receive Illinois Cares Rx drug coverage because you do not qualify on a 2011 Form IL-1363.
    1. Print out a blank copy of the form. Complete the form, make a copy for yourself and mail the original as directed on the form.
       or
    
    
    2. Fill in the form then print it. Print out at least 2 copies – one for yourself and one to mail as directed on the form.
  
  

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  • IL-1363-X: Amended Application for Form IL-1363 Benefits (4 pages: 2 form & 2 instructions)
    You should file an IL-1363-X if you need to amend your Form IL-1363, Application for Circuit Breaker and Illinois Cares Rx, for the years 2008, 2009, 2010 or 2011.
    1. Print out a blank copy of the form. Complete the form, make a copy for yourself and mail the original as directed on the form.
       or
    
    
    2. Fill in the form then print it. Print out at least 2 copies – one for yourself and one to mail as directed on the form.
  
  

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  • ADAD-16: Application for Illinois Cares Rx after Form IL-1363 has been filed in a claim year (Blue headline, 4 pages: 2 form & 2 instructions)
    You should complete this application only if you want help paying for drugs and did not make this request on your previously filed 2011 Form IL-1363 (NOT the 2010 Form IL-1363), Application for Circuit Breaker and Illinois Cares Rx.
    1. Print out a blank copy of the form. Complete the form, make a copy for yourself and mail the original as directed on the form.
       or
    
    
    2. Fill in the form then print it. Print out at least 2 copies – one for yourself and one to mail as directed on the form.

        

  • 2010 ADAD-16: Application for Illinois Cares Rx after Form IL-1363 has been filed in a claim year (Green headline, 5 pages: 3 form & 2 instructions)
    You should complete this application only if you want help paying for drugs and did not make this request on your previously filed 2010 Form IL-1363 (NOT the 2009 Form IL-1363), Application for Circuit Breaker and Illinois Cares Rx.
    1. Print out a blank copy of the form. Complete the form, make a copy for yourself and mail the original as directed on the form.
       or
       
       
    2. Fill in the form then print it. Print out at least 2 copies – one for yourself and one to mail as directed on the form.

HIPAA Forms

The information you disclose on Form IL-1363 is protected information under federal privacy and state confidentiality laws. For more information, see the Illinois Cares Rx Program Privacy Notice below.

If you want someone else to contact us about your Form IL-1363 or prescription drug benefits, you must send us a copy of documentation to show that the person is your legal guardian or has the appropriate power of attorney to act for you on such issues.

If you do not have this type of documentation and you want someone else to contact us about your Illinois Cares Rx application or benefits, you must call us or send us a completed Form ADAD-PN3, Authorization for Use or Disclosure of Medical Information (see below).

• ADAD-PN: Illinois Cares Rx Program Privacy Notice (2 pages, 22 KB)
  This notice describes how medical information about you may be used and disclosed and how you can get access to this information.



• ADAD-PN3: Illinois Cares Rx Program Authorization for Use of Disclosure of Medical Information (1 page, 19 KB)



• ADAD-PN4: Illinois Cares Rx Program Revocation of Authorization (1 page, 17 KB)