Registered Users Log-in:

E-mail Address:


Forgot Password?
Patient Assistance Information

Lilly Cares Patient Assistance Program

Lilly Cares Program
PO Box 230999
Centerville, VA 20120
Phone : 800-545-6962
Fax: 844-431-6650
> 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.
> 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.
> Up to a 120-day supply.
Ship To
> Medication is sent to the Doctor's office within 4 weeks.
> 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.
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
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