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PatientOne Oncology
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PO Box 4280
Gaithersburg, MD 20885
Phone
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(866)472-8663
Ext opt 2
Fax:
(877)366-0585
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Eligibility
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This program is intended for patients that are uninsured or are underinsured for needed medication. Medicare part D eligibility not specified. Income must be at or below 500% of FPL. Must be US resident. |
| Who Can Apply
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Call for application to be faxed or download from website. Doctor must complete application and sign. Patient must complete application, sign, and attach copy of income. Healthcare Provider will be notified via fax of decision. |
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Required
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Must be used for on-label diagnosis |
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Supply
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Amount/supply varies. Doctor/Doctor's office must complete replacement form for refills. Refill limit is not specified. New application must be completed every 12 months. |
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Ship To
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Medication will be shipped to Doctor's office. |
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Note
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The patient and physician must submit information to PatientOne for a benefits investigation before application will be given for the assistance program. For underinsured patients program helps connect patients with programs that can help them cover the cost of copayments and deductibles. Patients who do not have prescription insurance are reviewed for eligibility into the PatientOne patient Lilly assistance program.
Certification of Brand Name Drug Usage Form only needs to be completed for those seeking assistance for Gemzar. |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
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| Alimta injection |
| Cyramza injection |
| Erbitux |
| Gemzar injection |
| Portrazza |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form PatientOne Oncology |
(Requires Acrobat Reader) 
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Lilly Cares Patient Assistance Program
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Lilly Cares Program
PO Box 230999
Centerville, VA 20120
Phone
:
800-545-6962
Fax:
844-431-6650
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Eligibility
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This program is intended for patients that are uninsured. Medicare Part D patients eligibility is determined case by case. Patient must be under 65 years of age. Income requirements for this program vary. Must be a US citizen, Puerto Rico & US Virgin Island residents are not eligible. |
| Who Can Apply
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Anyone requesting assistance can call to request a faxed application or download it from the website. If denied the Patient will be notified in writing. |
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Required
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The doctor must fill out a section and sign the application.The patient must fill out a section, sign the application and attach required documents. |
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Supply
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Up to a 120-day supply. |
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Ship To
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Medication is sent to the Doctor's office within 4 weeks. |
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Note
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A refill/reorder form is included with each shipment that must be filled out and returned to get the next shipment. Once a year a new application with financial documentation is needed. |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
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| Cialis Tablet |
| Cymbalta capsule; delayed release |
| Effient Tablet |
| Evista Tablets |
| Forteo injectable; subcutaneous |
| Glucagon injection |
| Glucagon injection; emergency kit |
| Humalog 75/25 Injection |
| Humalog Injection |
| Humalog injection; cartridge |
| Humalog KwikPen injection; prefilled pen |
| Humalog Mix 50/50 injection |
| Humalog Mix 50/50 KwikPen injection; prefilled pen |
| Humalog Mix 50/50 Pen injection; prefilled pen |
| Humalog Mix 75/25 injection |
| Humalog Mix 75/25 Pen injection; prefilled pen |
| Humalog Mix50/50 |
| Humalog Pen injection; prefilled pen |
| Humalog U-200 KwikPen injection; prefilled pen |
| Humatrope injection |
| Humulin 70/30 injection |
| Humulin N injection |
| Humulin R (U-100) injection |
| Humulin R (U-500) injection; concentrated |
| Prozac capsule |
| Prozac Weekly capsule; delayed release pellets |
| ReoPro Injection |
| Strattera capsule |
| Symbyax capsule |
| Trulicity injection |
| Zyprexa Relprevv suspension; extended release |
| Zyprexa tablet |
| Zyprexa Zydis tablet; orally disintegrating |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form Lilly Cares Patient Assistance Program |
| (Requires Acrobat Reader)
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