Application Form Instructions - Lilly Cares
PP-AP-US-0286 3/2018 ©Lilly USA, LLC 2018. ALL RIGHTS RESERVED. Page 1 Lilly Cares Foundation Patient Assistance Program PO Box 13185 La Jolla, CA 92039
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LILLY CARES FOUNDATION Patient Assistance …
www.lillycares.comPage 2 of 6 LILLY CARES FOUNDATION Patient Assistance Program—Oncology Hours of Operation: Monday through Friday 8 A to 5 P ET Address: PO Bo 13185 La olla, CA 92039
LILLY CARES FOUNDATION Patient Assistance Program …
www.lillycares.comThe Lilly Cares Foundation, Inc. (“Lilly Cares”) is a nonprofit organization that offers a patient assistance program (“Program”) to help qualifying patients obtain certain Eli Lilly and Company (“Lilly”) medications at no cost.
LILLY CARES FOUNDATION Patient Assistance Program …
www.lillycares.com•Lilly Cares will send an autodialed, pre-recorded text message (Standard text message and data rates apply). •You can opt out at any time by calling 1 -800 545 6962. •Lilly Cares is not responsible if a communication is not delivered due to technical difficulties like server issues, phone carrier outages, or discontinued service.
Patient Name: Date of Birth: Today’s Date: Address:
www.lillycares.comBasaglar® (insulin glargine injection) U-100 KwikPen® Glucagon Emergency Kit (glucagon for injection) 1 mg Kit. Humalog® Mix 50/50™ (insulin lispro protamine and insulin lispro injectable suspension) U-100 vialU-100 KwikPen® Humalog® Mix 75/25™ (insulin lispro protamine . and insulin lispro injectable suspension) U-100 KwikPen ...