Lilly Cares Patient Assistance Application online and PDF

The Lilly Cares Foundation is a nonprofit organization that provides the Lilly Cares Patient Assistance Program to residents of the United States of America. This helps all eligible patients or applicants to get some of the medicines of Eli Lilly and the company at no cost.

The Lilly Cares application is available for qualified patients who want to apply and get the available medications for free through this Program.

You can access the online application from the official portal at www.lillycares.com. it is the fastest way to apply for Lilly Care application. you can also download and print paper applications and submit them through fax or mail.

Table of Contents

Check Your Eligibility Requirements

You must meet the eligibility criteria to apply for the Lilly Cares program application.

You must be a permanent resident of the United States, including Puerto Rico and the U.S. Virgin Islands.
Your healthcare provider has prescribed an eligible Lilly medicine.
The following applies to you regarding your insurance coverage:
- You are not enrolled in Medicaid, Full Low Income Subsidy (LIS, “Extra Assistance”), or Veterans (VA) benefits.
- You do not have an insurance plan that needs you to apply for the Lilly Cares program as a condition, requirement, or prerequisite to coverage for Eli Lilly and Company’s relevant drugs. A non-comprehensive list of these types of ineligible programs, it is also known as alternative funding programs, patient advocacy programs, or special networks, is set provided below.
  - 1) You have no insurance.
  - 2) You have Medicare Part D.
  - 3) With respect to oncology products, you have Medicare Part B but no supplemental or secondary insurance (e.g., private insurance offered by a former employer, Medigap, or Medicare Advantage).
You must meet the household income guidelines for the program.

Eligibility Under Household Income Guidelines:

Total number of persons in the household;
Total annual income, including the income of all earners in your household
To qualify for the Lilly Care program, your family’s yearly income before taxes cannot exceed the values listed below.

Annual Adjusted Gross Income Limit

Medication Groups	1 Person Household*	2 Person Household*	3 Person Household*	4 Person Household*	5 Person Household*	6 Person Household*
Group 1 Medications	$43,740	$59,160	$74,580	$90,000	$105,420	$120,840
Group 2 Medications	$58,320	$78,880	$99,440	$120,000	$140,560	$161,120
Group 3 Medications	$72,900	$98,600	$124,300	$150,000	$175,700	$201,400

Lilly Cares Patient Assistance Application

The Lilly Cares Patient Assistance application is available for patients who are eligible for the program. They can apply for financial assistance from the Lilly Cares Foundation to assist in paying for Eli Lilly and Company medications. There are several types of applications available online at www.lillycares.com and printable (that can be downloaded from here).

Submit an online application
Download a blank application or Print it
Use of Third Parties to Apply

1. Online Application

Here are the steps to apply for Lilly Cares Patient Assistance application online.

Go to the Application form through the www.lillycares.com/how-to-apply page.
Click on Online Application.
Fill out the required information such as:
- Patient information
- Medication information
- Patient income information
- Healthcare provider information
- Insurance information
Upload documents required (e.g. oncology medication documentation of insurance denial and denied appeal).
After that continue and complete the application.

2. Download Application PDF

You can download and Print the Lilly Cares Patient Assistance application form PDF and fill it out with the required information. You need to follow the steps below.

Steps:

Check your eligibility requirements for the Lilly Cares Program.
Read the privacy notice.
Fill out the patient information section.
You need to read and sign the Patient Certification Agreement.
Read and sign the Health Insurance Portability and Accountability Act (HIPAA) authorization.
Ask your healthcare provider to complete and sign the Healthcare Provider or Prescriber Section.
Fax the completed and signed application to Lilly Cares or your healthcare provider’s office.
- Lilly Cares Patient Assistance Program
  PO Box 501847
  San Diego, CA 92150
  Fax: 1-844-431-6650

After that, your application will be reviewed, and a letter will be sent to you and your healthcare provider, notifying you whether you qualify or not for the Lilly Cares Program.

Apply by Third Parties

It is clearly mentioned that the Lilly Cares Foundation does not charge patients a fee for assistance with enrollment or application, medication refills, or participation in the program.

Lilly Cares is not affiliated with third-party communities that charge for the service, to ensure the program features you can contact the customer care number at 1-800-545-6962.

Lilly Cares application status

You can check the Lilly Care application status by logging into your account and through customer care.

Lilly Cares Customer Service – 1-800-545-6962