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Updated February 07, 2014
Humalog

Lilly Cares Patient Assistance Program

This program provides brand name medications at no or low cost.

Provided by: Eli Lilly & Company

Lilly Cares Program
PO Box 230999
Centreville, VA 20120

TEL: 800-545-6962


ALT PHONE:
FAX: 703-310-2534 		Languages Spoken:

English

Program Website
 

Patient Assistance Applications

Lilly Cares Patient Assistance Program Application

Lilly Cares Refill Authorization Form
 

Medications
  • Humalog Injection 10mL/vial, 3mL/vial (insulin lispro injection (rDNA origin))
  • Humalog Injection; Cartridge 3mL (insulin lispro injection (rDNA origin))
  • Humalog  Injection; Prefilled Pen 3mL (insulin lispro injection (rDNA origin))
 

Eligibility Requirements
Insurance Status Must have no prescription coverage
Those with Part D Eligible? No, must be ineligible
Income At or below 300% of FPL
Diagnosis/Medical Criteria Not specified
US Residency Required? Puerto Rico & US Virgin Island residents are not eligible
   

Application
Obtaining Call or download
Receiving Faxed
Returning Mail or fax
Doctor's Action Complete section, sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Doctor notified
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