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

Humulin 70/30

Lilly Cares Patient Assistance Program

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

Provided by: Eli Lilly & Company

PO Box 13185
La Jolla, CA 92039

TEL: 800-545-6962


ALT PHONE: 800-545-5979
FAX: 844-431-6650
Languages Spoken:

English

Program Website

 

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