| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 1 of 2. Scroll down to see them all. |
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Lilly Cares Foundation Patient Assistance ProgramThis program provides medication at no cost. |
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Provided by: Lilly USA, LLC. |
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PO Box 13185 TEL: 800-545-6962FAX: 844-431-6650 |
Languages Spoken:
English, Spanish |
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Program Applications and Forms |
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Lilly Cares Foundation Patient Assistance Program Application |
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Lilly Cares Foundation Patient Assistance Program Application (Spanish) |
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Medications |
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Eligibility Requirements |
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| Insurance Status | *Contact program for details. | ||
| Those with Part D Eligible? | Yes | ||
| Income | Varies | ||
| Diagnosis/Medical Criteria | Not specified | ||
| US Residency Required? | Must reside in the US, Puerto Rico or the USVI | ||
Application |
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| Obtaining | Call, download or apply online | ||
| Receiving | Faxed | ||
| Returning | Fax, mail or submit online | ||
| Doctor's Action | Complete section, sign, attach required documents | ||
| Applicant's Action | Complete section, sign, attach required documents | ||
| Decision Communicated | Patient and Doctor are notified | ||
| Decision Timeframe | Not specified | ||
Medication |
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| Amount/Supply | Up to 120 day supply | ||
| Sent To | Doctor's office or patient's home | ||
| Delivery Time | Contact Program for Details | ||
| Refill Process | Contact program for details. | ||
| Limit | Not specified | ||
| Re-application | New application, new documentation yearly | ||
Additional Information |
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| Please visit www.LillyCares.com or call 800-545-6962 for more information. Additional products may be available. Please contact the program for a complete product listing. Lilly donates products to the Lilly Cares Foundation Patient Assistance Program. |
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| Updated August 26, 2021 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 2 of 2. | |||
Rx Outreach MedicationsThis program provides medication at low cost. (Most brand names are provided for reference purposes only) |
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Provided by: Rx Outreach |
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PO Box 66536 TEL: 888-796-1234FAX: 800-875-6591 |
Languages Spoken:
English, Spanish |
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Program Applications and Forms |
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Rx Outreach Application
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Rx Outreach Application (Spanish)
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Rx Outreach Refills Form |
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Rx Outreach Medication List (Alphabetized) |
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Rx Outreach Medication List (by Disease State)
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Rx Outreach Diabetic Supplies Order Form (Prodigy) |
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Medications |
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Eligibility Requirements |
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| Insurance Status | May have insurance | ||
| Those with Part D Eligible? | Yes | ||
| Income | Determined case by case | ||
| Diagnosis/Medical Criteria | Not required | ||
| US Residency Required? | Must reside in the US | ||
Application |
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| Obtaining | Call, download or apply online | ||
| Receiving | Faxed, mailed or downloaded from website | ||
| Returning | Fax or E-Prescribe online | ||
| Doctor's Action | Give prescription to patient | ||
| Applicant's Action | Complete section and sign | ||
| Decision Communicated | Medications sent if accepted. If denied patient and doctor notified | ||
| Decision Timeframe | Usually same day | ||
Medication |
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| Amount/Supply | Varies | ||
| Sent To | Doctor's office or patient's home | ||
| Delivery Time | Not specified | ||
| Refill Process | Company contacts patient to arrange | ||
| Limit | Only limited by manufacturer's guidelines | ||
| Re-application | New application yearly | ||
Additional Information |
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| Rx Outreach has expanded the eligibility guidelines beyond 400% FPL to include people affected by COVID-19. Some medications are available for a fee of $20 for up to a 180 day supply. Check the Rx Outreach website for the exact price and most current medication list. Contact Program for Spanish Application(s)/Form(s). |
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| Updated October 18, 2021 | |||
