Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
Humalog |
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Lilly Cares Patient Assistance ProgramThis program provides brand name medications at no or low cost @if> |
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Provided by: The Lilly Cares Foundation, Inc. |
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PO Box 13185 TEL: 800-545-6962FAX: 844-431-6650 |
Languages Spoken:
English |
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Program Applications and Forms |
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Lilly Cares Patient Assistance Program Application (pages 4-9) |
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Lilly Cares Patient Assistance Application Instructions (pages 1-3) |
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Lilly Cares Prescription FAX Form (Forteo) |
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Lilly Cares Prescription FAX Form (Humatrope) |
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Lilly Cares Prescription FAX Form (Humulin R U-500) |
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Lilly Cares Prescription FAX Form (Taltz) |
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Lilly Patient Assistance Program Brochure |
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Medications |
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Eligibility Requirements |
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Insurance Status | Must have no prescription coverage | ||
Those with Part D Eligible? | Determined case by case | ||
Income | Varies | ||
Diagnosis/Medical Criteria | Must be under 65 years of age | ||
US Residency Required? | Puerto Rico & US Virgin Island residents are not eligible | ||
Application |
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Obtaining | Call or download | ||
Receiving | Faxed | ||
Returning | Fax or mail | ||
Doctor's Action | Complete section and sign | ||
Applicant's Action | Complete section, sign, attach required documents | ||
Decision Communicated | Patient notified of denial in writing | ||
Decision Timeframe | Not specified | ||
Medication |
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Amount/Supply | Up to 120 day supply | ||
Sent To | Doctor's office | ||
Delivery Time | Within 4 weeks | ||
Refill Process | Refill/reorder form included with shipment | ||
Limit | Not specified | ||
Re-application | New application, new documentation yearly | ||
Additional Information |
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Updated March 19, 2018 |