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Program Details

Lilly Cares

Humalog KwikPen Mix 50/50 (insulin lispro injection (rDNA))
Address: PO Box 13185
La Jolla, CA 92039
Phone: 1-800-545-6962 Provider Phone:
Fax: 1-844-431-6650 Website: Program Website
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: Not Published
    Other Income Requirements: Varies
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    Attachments Required: Financial
    Physician License #
    Prescriber Signature
    Application may be
    Eligibility determination
    letter sent:
    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: 12/14/2017




    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)


    Print-friendly version

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