| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
Humalog |
|||
Lilly Cares Patient Assistance ProgramThis program provides brand name medications at no or low cost. |
|||
Provided by: Eli Lilly & Company |
|||
PO Box 13185 TEL: 800-545-6962ALT PHONE: 800-545-5979 FAX: 844-431-6650 |
Languages Spoken:
English |
||
Program Applications and Forms |
|||
Lilly Cares Patient Assistance Program Application |
|||
Lilly Cares Patient Assistance Program Refill Authorization Form |
|||
Lilly Patient Assistance Program Brochure |
|||
Lilly Cares Prescription FAX Form (Forteo) |
|||
Lilly Cares Prescription FAX Form (Humatrope) |
|||
Lilly Cares Prescription FAX Form (Taltz) |
|||
Medications |
|||
|
|||
|
|||
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 September 09, 2016 | |||
