| 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 |
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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 July 05, 2017 | |||
