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Patient Assistance Information

 
1 Program for Humalog Injection
 
 
Lilly Cares Patient Assistance Program

Lilly Cares Program
PO Box 230999
Centerville, VA 20120
Phone : 800-545-6962
Fax: 844-431-6650
Eligibility
> 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
> 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.
Required
> 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.
Supply
> Up to a 120-day supply.
Ship To
> Medication is sent to the Doctor's office within 4 weeks.
Note
> 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.
 
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.
 
Humalog Injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Lilly Cares Patient Assistance Program
(Requires Acrobat Reader