Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
 

Humalog

Lilly Cares Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: The Lilly Cares Foundation, Inc.

PO Box 13185
La Jolla, CA 92039

TEL: 800-545-6962


FAX: 844-431-6650 		Languages Spoken:

English

Program Website

 

Program Applications and Forms

Lilly Cares Patient Assistance Program Application (pages 4-9)

Lilly Cares Patient Assistance Application Instructions (pages 1-3)

Lilly Cares Prescription FAX Form (Forteo)

Lilly Cares Prescription FAX Form (Humatrope)

Lilly Cares Prescription FAX Form (Humulin R U-500)

Lilly Cares Prescription FAX Form (Taltz)

Lilly Patient Assistance Program Brochure
 

Medications
  • Humalog injection (insulin lispro (rDNA origin))
  • Humalog injection; cartridge (insulin lispro protamine (recombinant)/insulin lispro (recombinant))
 

Eligibility Requirements   
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
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
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

Updated March 19, 2018