18005456962 2026

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The document outlines the application process for the Lilly Cares Patient Assistance Program, which provides selected Lilly medications to qualifying individuals under age 65 who are legal residents of the U.S., lack health insurance, and meet specific income criteria. It details eligibility requirements, application steps, and the responsibilities of both patients and healthcare providers in the program.

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Click ‘Get Form’ to open the Lilly Cares Patient Assistance Program application in the editor.
Begin by filling out the Patient Section. Enter your name, address, date of birth, and contact information accurately.
In the Patient Income Information section, indicate the number of family members and your total gross household income. Ensure you have proof of income documents ready to upload.
Review the Patient Certification carefully. Confirm that all statements are true and sign where indicated.
Next, have your doctor complete the Doctor Section. They will need to provide their details and confirm your eligibility for the program.
Once both sections are completed, save your form and either mail or fax it along with copies of your proof-of-income documents to the Lilly Cares program using the provided contact information.

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