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How do I fill this out?
To fill out this form, start by confirming your eligibility. Then, proceed to read and sign the necessary agreements. Complete the patient and healthcare provider sections before submitting.
How to fill out the Lilly Cares Patient Assistance Program Application?
1
Confirm you qualify for the Lilly Cares Program.
2
Read the Privacy Notice.
3
Complete the Patient Information Section.
4
Read and sign the required agreements.
5
Ask your healthcare provider to complete and sign their section.
Who needs the Lilly Cares Patient Assistance Program Application?
1
Patients prescribed a Lilly medication.
2
Residents of the United States.
3
Individuals meeting specific income guidelines.
4
Patients not enrolled in Medicaid or VA benefits.
5
Those with insurance coverage constraints.
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You can use PrintFriendly to easily edit this PDF. Add your personal information, make corrections, and complete all required sections. Use our tools to ensure your form is ready for submission.
1
Open the PDF in the PrintFriendly editor.
2
Enter your personal and healthcare provider's information.
3
Read and sign the required sections.
4
Make any necessary corrections or additions.
5
Save and prepare your completed form for submission.
What are the instructions for submitting this form?
To submit this form, ensure all sections are completed and signed by you and your healthcare provider. Fax the completed application to 1-844-431-6650 or mail it to PO BOX 501847, San Diego, CA 92150. Include proof of claim denial and one appeal if applying for Group 4 medications.
What are the important dates for this form in 2024 and 2025?
Eligibility criteria may change annually based on Federal Poverty Level Guidelines. Be sure to check current guidelines each year before applying.
What is the purpose of this form?
The purpose of this form is to help qualifying patients receive specific Eli Lilly and Company medications at no cost through the Lilly Cares Patient Assistance Program. Applicants must meet eligibility criteria, including income guidelines and lack of certain insurance coverages, to receive assistance. The form collects necessary personal, health, and financial information to determine eligibility and facilitate the provision of medications.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information Section: Collects personal details, health condition, and insurance information.
- 2. Patient Certification Agreement: Requires the patient's acknowledgment and agreement to the program's terms.
- 3. HIPAA Authorization: Authorization for sharing and using health information as required by law.
- 4. Healthcare Provider/Prescriber Section: To be completed and signed by the healthcare provider or prescriber.
- 5. Proof of Insurance Claim Denial: Needed for applicants with specific insurance coverages applying for Group 4 medications.
What happens if I fail to submit this form?
Failing to submit this form means you will not be eligible for assistance through the Lilly Cares Program. This can result in out-of-pocket costs for medications.
- Denied Assistance: You will not receive the medications at no cost without the completed form.
- Medication Costs: You may need to pay full price for the prescribed medications.
- Missed Opportunities: Failing to qualify can limit your access to necessary treatments.
How do I know when to use this form?
- 1. Eligibility Confirmation: To verify if you meet the program's eligibility criteria.
- 2. Medication Application: To apply for receiving prescribed Lilly medications at no cost.
- 3. Insurance Denial: To provide proof of claim denial and appeal if applicable.
Frequently Asked Question
How can I apply to the Lilly Cares Program?
You must complete and submit the application form including necessary documentation and signatures from your healthcare provider.
What if I don't qualify based on income?
You may not be eligible if you don't meet the income guidelines. Review the eligibility criteria carefully before applying.
How do I know if my medication is covered?
Refer to the list of medications provided in the application document to check if your medication is included.
Can I reapply if my application was denied?
Yes, you can reapply if your circumstances change and you meet the eligibility requirements.
Where do I send my completed application?
Fax the completed application to 1-844-431-6650 or mail to PO BOX 501847, San Diego, CA 92150.
How do I know if my application was successful?
You will receive a letter notifying you and your healthcare provider of the application outcome.
Can I edit my application after submitting?
No, once submitted, you cannot edit the application. Ensure all information is accurate before submitting.
How can I get help with completing the application?
Call Lilly Cares at 1-800-545-6962 for assistance with the application process.
What if I have an appeal for a denied insurance claim?
Include proof of claim denial and one appeal with your application if applying for specific medications in Group 4.
How do I submit supporting documents?
Attach the relevant documents and fax or mail them along with your completed application.
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