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Patient Assistance Information

 
1 Program for Humulin R (U-100) 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.
 
Humulin R (U-100) 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