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Lilly Cares Patient Assistance Program
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Lilly Cares Program
PO Box 230999
Centerville, VA 20120
Phone
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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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