Lilly cares refill 2025

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The document is a refill authorization form for the Lilly Cares Patient Assistance Program, which provides medications to eligible patients at no charge. It outlines the necessary patient and prescriber information, attests to the healthcare provider's agreement to deliver medications only to qualifying patients, and includes legal disclaimers regarding confidentiality and program terms.

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Click ‘Get Form’ to open the Lilly Cares Refill Authorization Form in the editor.
Begin by filling in the patient’s name, address, and date of birth in the designated fields. Ensure accuracy as this information is crucial for processing.
In the section requesting a four-month supply, specify the product name, dosage, and quantity required. This ensures that the correct medication is sent.
Provide shipping information, including the prescriber’s name and office/clinic details. Avoid using PO Box or third-party vendor addresses to ensure timely delivery.
The healthcare provider must read and agree to the attestation statements. This includes confirming their licensure and understanding of program requirements.
Finally, have the prescriber sign and print their name along with their license number and state of licensure before submitting the form.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I check the status of my Lilly Cares application?

How do I check the status of my Lilly cares application? I may call Lilly Cares at 1-800-545- 6962 for this information.

What is the Lilly discount program?

Lilly provides automatic discounts for people with commercial insurance who buy their Lilly insulin at participating retail pharmacies. The automatic discount brings the monthly prescription down to $35 for people with commercial insurance plans without requiring use of a Savings Card.

What is the income limit for Lilly Cares?

Annual Adjusted Gross Income Limit Medication Groups1 Person Household*5 Person Household* Group 2 Medications 1 Person Household*: $62,600 5 Person Household*: $150,600 Group 3 4 Medications 1 Person Household*: $78,250 5 Person Household*: $188,2501 more row

Who is eligible for the patient assistance program?

Patient assistance programs (PAPs) help people with no health insurance and those who are underinsured afford medications. These programs are managed by pharmaceutical companies, nonprofits, and government agencies. PAPs may cover the full cost of medications or provide a discount.

What are the income limits for Dupixent?

Those who may qualify must be at least 18 years of age or older, a resident of the 50 United States, the District of Columbia, Puerto Rico, Guam or the USVI, and demonstrate a financial need with a total annual adjusted gross income of $100,000 or less.

lilly cares refill form

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Who is eligible for Lilly Cares patient assistance?

To qualify, you must meet all the requirements listed below: Your healthcare provider has prescribed a qualifying Lilly medication. You are a permanent resident of the United States, (inclusive of Puerto Rico and the U.S. Islands). You meet the household income guidelines for the program (shown below).

How to get help with Trulicity?

How to Get Trulicity Prescription Assistance. To get started, apply with Simplefill online, or call us at 1(877)386-0206. One of our advocates will call you within 24 hours and conduct a phone interview.

What is the annual income for Eli Lilly?

Eli Lilly annual net income for 2022 was $6.245B, a 11.88% increase from 2021.