COVID-19 Update from Lilly Cares Foundation Read Message >>

Lilly Cares Foundation is closely monitoring the coronavirus (COVID-19) pandemic. We do not anticipate shortages of Eli Lilly and Company medications provided for those in our patient assistance program (PAP).

If your job was affected by the COVID-19 crisis you may qualify for the Lilly Cares PAP to receive your prescribed Lilly medication for free. Read eligibility details on this website and call us at 1-800-545-6962 with questions. If your proof-of-income document does not reflect your recent change of income, please include a brief letter with your application explaining your situation.

At this time, only submit your application using our online submission process or via fax using the fax number located on the bottom of the application form. Please do not mail your application.

  • Contact us at 1-800-545-6962 Mon-Fri 8am-6pm EST
  • Contact us at 1-800-545-6962 Mon-Fri 8am-6pm EST
Resources
Lilly Cares Foundation Patient Assistance Program Applications

Electronic Application:

Click here Lilly Cares Foundation Patient Assistance Program Online Application to begin the online application process.


Printable Applications:
Lilly Cares Foundation Patient Assistance Program Application
Lilly Cares Foundation Patient Assistance Program Oncology Application

For more information about Lilly’s privacy practice, please view the Privacy Statement.

Lilly Cares Refill Authorization Form:

Lilly Cares Fax Refill Form when ordering a refill for enrolled Lilly Cares patients.
Prescription Fax Form template for a Lilly Cares medication:
The Healthcare provider may use these optional prescription fax forms when ordering refills for some medications.

Diabetes Prescription Fax Form when ordering Baqsimi, Basaglar, Glucagon, Humalog, Humulin, Lyumjev, and Trulicity.
Emgality Prescription Fax Form when ordering Emgality.
Forteo Prescription Fax Form when ordering Forteo.
Humatrope Prescription Fax Form when ordering Humatrope.
Olumiant Prescription Fax Form when ordering Olumiant.
Taltz Prescription Fax Form when ordering Taltz.
Lilly Cares Foundation Patient Assistance Program brochure:
If you know someone who may benefit from the Lilly Cares Foundation Patient Assistance Program, this brochure provides our toll-free number and website information.