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Program Details

LILLY
Lilly Cares

Humulin 70/30 (isophane human insulin (rDNA); human insulin (rDNA))
 
CONTACT INFO
Address: PO Box 13185
La Jolla, CA 92039
Phone: 1-800-545-6962 Provider Phone:
Fax: 1-844-431-6650 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Patient must be uninsured or have Medicare Part D.
  • Patients must not be eligible for or enrolled in Medicaid or Veteran’s Administration Benefits.
  • Patients with Medicare Part D patient must have spent $1,100 on medicine this calendar year.
  • NOTE: Humatrope Paitients must have a “No Funding Letter” from Humatrope Direct Connect. Contact Humatrope Direct Connect at 1-84Humatrope if you need this letter. Patients with insurance may be eligible for Humatrope if their insurance does not cover the medication.
  • Income at or below: Single % FPL
      Couple % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
    Other Income Requirements: Income limits are 300% FPL for Group A medications and 500% of FPL for Group B medications.
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Financial
    Prescription
    Physician License #
    Required:
    DEA
    State
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    MEDICATION
    Receives: Medication
    Shipped To: Provider
    Quantity in Shipment: Up to a 4-month supply
    Delivery Time: 2-4 weeks
    Re-application Policy: New application every 12 months
    New financial information every 12 months
    Refill Policy: Completed Refill Request Forms should be faxed to program for refills.
    Other Information:

    Last Updated: 04/27/2016

     

     

     


    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.


    DocumentForm (English)


    Document Refill (English)



     

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