Loading…
Lilly Cares Foundation Patient Assistance Program
Application eService

Welcome to the Lilly Cares Foundation Patient Assistance Program Application eService website. The Lilly Cares Foundation, Inc., (“Lilly Cares”) is a nonprofit organization providing certain Lilly medications at no cost to qualifying patients in need.

You can submit an application to Lilly Cares online through this website by completing a few steps.

Steps to apply online to Lilly Cares

Our online application process will guide you through the steps needed to complete and submit your portion of the online application:

  • Step One: Enter your information into the online application.
  • Step Two: Upload (attach electronic copies of) your supporting documents.
  • Step Three: Submit your application information.
  • Step Four: Electronically sign (eSignature, eSign, E-SIGN) and date the certifications (agreements) and consents to begin processing and review of your application. eSignature is required for online applications, please proceed only if you are willing to eSign the application upon completion.
  • Step Five: You will receive notification of enrollment by letter (and text message of approval if this option is selected) and healthcare provider will receive by fax.
Information about Applying Online
  • To apply to Lilly Cares online, a patient applicant and their healthcare provider will submit application information separately. To complete the online application, you can type your information directly in this website and then upload (attach electronic copies of) required documents. Once a patient or healthcare provider submits their portion of an application, Lilly Cares will then provide a link through an email to the other party (patient or healthcare provider) to obtain their needed information to complete the application.
  • To submit a Lilly Cares application online, the person starting the application process must provide an accurate email address for both the patient and the HCP who will be completing the application. If the person starting the application process does not know the correct email addresses for both individuals, a paper version of the Lilly Cares application may be submitted and is available for printing from the Resources tab of www.lillycares.com or by calling Lilly Cares at 1-800-545-6962.
  • The online application process will take about 15-20 minutes. As you work through the online application process you will not be able to save information to complete the application process at a later time. Please note, to protect your personal information, the submission process will time out after 30 minutes of inactivity, and you will lose all entered information.

Below you will find a list of items you will need before you start the application process. Before you start, please make sure that you have electronic copies of any required documents described below. If you do not have electronic copies of required documents available now, please fill out a paper application and fax it to Lilly Cares. A paper application is available at www.lillycares.com or by calling Lilly Cares at 1-800-545-6962. Additional program information is available on the Lilly Cares website.

Items needed for patient to complete the online application
  • Personal email address.
  • Correct email address for healthcare provider.
  • Proof of income (one document verifying household income such as last year’s filed income tax return; W-2 or 1099; current pay stubs or earnings statements; unemployment benefits statement; Social Security income yearly benefit statement; statements of interest dividends, or other income).
Medicare Part D
  • For Medicare Part D eligible patients, a copy of the front of your Medicare Part D card (Except patients prescribed infused oncology products) is required.
  • For Medicare Part D patients (Except patients prescribed Forteo, Olumiant, Taltz or Verzenio), proof of spending $1,100 dollars on prescription medications this calendar year [this can be an Explanation of Benefits Statement (EOB) or summary from your pharmacy] is required.
Low Income Subsidy (Household Income < $22,221) Some US residents with limited income (approximately less than $16,389 individual, or less than $22,221 married couple living together) may be able to get Extra Help, known as Low Income Subsidy (LIS), to assist with costs related to a Medicare prescription drug plan. For assistance in determining if you qualify for LIS, please call the Social Security Administration at 1-800-772-1213. If your gross income is equal to or less than the income described, please submit a copy of a Low Income Subsidy (LIS) decision letter. Medicare Part D patients who qualify for full LIS are not eligible for Lilly Cares. LIS denial is not required for residents of Puerto Rico.
Humatrope Patients with Medicaid or VA Benefits may apply. Patients must submit a “no funding letter” from Humatrope® DirectConnect which states they have no insurance benefits for their Humatrope therapy. Contact Humatrope DirectConnect at 1-84Humatrope (1-844-862-8767) if you need this letter. A “no funding letter” is not required for Medicare Part D patients.
Items needed for healthcare provider to complete the online application
  • Healthcare provider email address. Email address must be accessed by the healthcare provider.
  • Correct email address for patient applicant.
  • If prescribing Forteo®, Humatrope®, Olumiant® , Taltz®, or Verzenio for the applicant, a signed hard copy prescription or signed optional prescription template must be submitted as an attachment with the eApplication. An optional prescription template for these products is available on the Resources tab of www.lillycares.com.
Oncology If prescribing an oncology medication for the patient (oral or infused products) and the patient has insurance that does not cover the medication, attach documentation that shows no coverage for the medication (such as insurance documentation of the initial claim denial and two denied appeals; insurance documentation that maximum benefit has been reached; insurance documentation of plan exclusion; or no coverage letter from Lilly PatientOne (1-866-4PatOne or 1-866-472-8663) or Verzenio Continuous Care (1-844-VERZENIO or 1-844-837-9364).