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Program Details

LILLY
Lilly Cares

Humalog KwikPen Mix 50/50 (insulin lispro injection (rDNA))
 
CONTACT INFO
Address: PO Box 501847
San Diego, CA 92150
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 may be eligible if insurance does not cover their medication. Contact program for details.
  • Patients must not be eligible for or enrolled in Medicaid or Veterans Administration Benefits.
  • Contact program for additional details. (Note: Humatrope patients with VA and Medicaid benefits may be eligible.)
  • Income at or below: Not Published
    Other Income Requirements: Income limits vary by medication. Contact program for details.
    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
    Physician License #
    Required:
    DEA
    State
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Both Provider and Patient
    MEDICATION
    Receives: Medication
    Shipped To: Either Provider and Patient
    Quantity in Shipment: Up to a 120-day supply
    Delivery Time: Not Published
    Re-application Policy: New application every 12 months
    New financial information every 12 months
    Refill Policy: Contact program
    Other Information:

    Last Updated: 12/06/2023

     

     

     


    Application Forms
    & Instructions

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


    DocumentForm (English)


    Document Form (Spanish)



     

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