LILLY CARES® FOUNDATION, INC.

Patient Assistance Program Application

The Lilly Cares Foundation, Inc. (“Lilly Cares”) is a nonprofit organization that offers the Lilly Cares Patient Assistance Program (“Program”) to
help qualifying patients obtain certain Eli Lilly and Company medications at no cost. This application form is for patients who would like to apply
to receive the available medication(s) at no cost through the Program.
An electronic application is available at www.lillycares.com and is recommended to reduce paperwork and potential delays.

Medications Provided by the Lilly Cares Program

New applications for Trulicity® are temporarily not being accepted, except for limited medical exception cases. Visit lillycares.com/how-to-apply
for medical exception requirements and form. Lilly Cares will accept applications for re-enrollment of those currently enrolled for Trulicity.

Group 1 Medications Group 2 Medications Group 3 Medications Group 4 Medications

• Cialis® (tadalafil) tablets • Basaglar® (insulin glargine • Ebglyss™ (lebrikizumab-lbkz) for • Alimta® (pemetrexed for injection)†
• Emgality® (galcanezumab-gnlm) injection) injection • Cyramza® (ramucirumab) injection†
injection • Humalog® (insulin lispro injection) • Humatrope® (somatropin) for injection • Erbitux® (cetuximab) injection†
• Forteo® (teriparatide injection) • Humulin® (human insulin) • Omvoh® (mirikizumab-mrkz) • Jaypirca® (pirtobrutinib) tablets
• Reyvow® (lasmiditan) • Lyumjev® (insulin lispro-aabc) infusion† • Kisunla™ (donanemab-azbt)
• Omvoh® (mirikizumab-mrkz) injection injection†
• Trulicity® (dulaglutide) injection injection
• Olumiant® (baricitinib) tablets • Retevmo® (selpercatinib) tablets
• Taltz® (ixekizumab) injection • Verzenio® (abemaciclib) tablets

†  
indicates infused medication

To qualify, you must meet all the requirements listed below:

• Your healthcare provider has prescribed a qualifying Lilly medication.
• You are a permanent resident of the United States, (inclusive of Puerto Rico and the U.S. Virgin Islands).
• You meet the household income guidelines for the program (shown below).
• You are not enrolled in Medicaid, full Low-Income Subsidy (LIS, “Extra Help”), or Veterans (“VA”) Benefits.
• The following applies to you regarding your insurance coverage:
○ Medication Group 1, 2, and 3 Either:
1) You have no insurance, or 2) you have Medicare Part D (not applicable to infused medications†), or 3) you have Medicare Part B but have no
supplemental or secondary insurance (e.g., private insurance offered by former employer, Medigap, Medicare Advantage).
○ Medication Group 4 Either:
1) You have no insurance, or 2) you have Medicare Part D (not applicable to infused medications†), or 3) you have Medicare Part B but have no
supplemental or secondary insurance (e.g., private insurance offered by former employer, Medigap, Medicare Advantage), or 4) if your insurance
does not cover the medication, you may still qualify. For details, visit: https://www.lillycares.com/assets/pdf/insuranceverification.pdf.
• For ALL Medications, you do not have an insurance plan or third party that requires you to apply to the Lilly Cares Program as a condition,
requirement, or prerequisite for coverage of specific Eli Lilly and Company medications. Additional information on such ineligible programs, often
referred to as alternative funding programs, for-profit patient advocacy programs, or specialty cost-containment networks (collectively known as
"AFPs"), is provided below*.
• If applying for an infused medication, the treatment must be provided in an outpatient setting.
• If your healthcare provider is seeking replacement product for an infused oncology medication that you have already received, you must have
received treatment within the last 180 days.
Annual Adjusted Household Income Limit
The dollar amounts listed in this table are based on Federal Poverty Level (FPL) Guidelines. Income limits are subject to change on an annual
basis; current limits reflect 2025 FPL guidelines. Please visit www.aspe.hhs.gov/poverty for the most current guidelines.

Total Number of People in your Household (Including you and all family members) 1 2 3 4
Group 1 Medications (at or below 300% FPL) $46,950 $63,450 $79,950 $96,450
Group 2 Medications (at or below 400% FPL) $62,600 $84,600 $106,600 $128,600
Group 3 & Group 4 Medications (at or below 500% FPL) $78,250 $105,750 $133,250 $160,750
If you live in Alaska, Hawaii, or have more than four people in your household please call us at 1-800-545-6962 for adjusted gross income limits.

*The Lilly Cares Foundation offers the Lilly Cares Patient Assistance Program as a charitable program for patients in financial need based on income and other
eligibility criteria. If an employer, plan, or other third-party directs patients to apply to the Lilly Cares Program as a condition of, requirement for, or prerequisite to
coverage, or in any way adjusts coverage based on application to or availability of the Lilly Cares Program, those individuals are not eligible for the Lilly Cares
Program. Moreover, if an employer or plan requires an application to Lilly Cares be submitted by or with an AFP, as defined above, that applicant is not eligible
for the Lilly Cares Program, even if eligibility criteria are otherwise met. Applications that violate these requirements will be blocked from participating in the
Lilly Cares program, and Lilly Cares reserves the right to take further action as necessary, including against third parties. More information regarding Lilly Cares
eligibility criteria as well as a list of AFPs is available at https://lillycares.com/assets/pdf/toapplycheckEligibility.pdf.

Lilly Cares Foundation Patient Assistance Program | PO BOX 501847 | San Diego, CA 92150
Phone: 1-800-545-6962 | Fax: 1-844-431-6650 | www.lillycares.com
PP-AP-US-0672 03/2025 © Lilly Cares® Foundation 2025. All rights reserved. Page 1 of 9
How do I apply to the Lilly Cares Program?
To apply, you must complete the following steps:

Access the latest Program application at www.lillycares.com or by contacting Lilly Cares. Outdated applications will
1 not be accepted.

2 Confirm you qualify for the Lilly Cares Program (page 1)

3 Read the Privacy Notice (page 3)

4 Complete the Patient Information Section (pages 4 and 5)

5 Read and sign the Patient Certification Agreement (page 6)

6 Read and sign the Health Insurance Portability and Accountability Act (HIPAA) Authorization (page 7)

7 Ask your healthcare provider to complete and sign the Healthcare Provider/Prescriber Section (pages 8 and 9)

Fax the completed and signed application to Lilly Cares (or have your healthcare provider’s office do this
8 for you). If you have insurance and you’re applying for a Group 4 or an infused Medication, include insurance
verification documentation.* For details, visit: https://www.lillycares.com/assets/pdf/insuranceverification.pdf.
Fax number: 1-844-431-6650

*Insurance documentation is not required for Medicare Part D patients applying for a Group 4 self-administered product

9 After review of your application, a letter will be sent to you and your healthcare provider notifying you of
whether you qualify for the Lilly Cares Program.

Use of Third Parties to Apply

Lilly Cares does not charge patients a fee for help with enrollment, medication refills, or for participation in the program. Lilly Cares
is not affiliated with third parties that charge for assistance that Lilly Cares provides to you at no cost. For support, please call Lilly
Cares at 1-800-545-6962.

Lilly Cares Foundation Patient Assistance Program | PO BOX 501847 | San Diego, CA 92150
Phone: 1-800-545-6962 | Fax: 1-844-431-6650 | www.lillycares.com
PP-AP-US-0672 03/2025 © Lilly Cares® Foundation 2025. All rights reserved. Page 2 of 9
Privacy Notice
This Privacy Notice (“Notice”) is to provide you with information about the personal information, including health information and
financial information, that the Lilly Cares Foundation, Inc. (“Lilly Cares”) (collectively, “we”, “us” or “our”) may collect, use, disclose,
or otherwise process, and your rights and choices with respect to your information. This Notice is intended to supplement the
Eli Lilly and Company Privacy Statement (https://privacynotice.lilly.com) and the Consumer Health Privacy Notice (https://www.lillyhub.
com/legal/lillyusa/CHPN.html) that can be accessed in the footers of Eli Lilly and Company’s websites. Lilly Cares may transmit
personal information about you to Eli Lilly and Company and its affiliates worldwide including their employees, agents, contractors,
vendors, subsidiaries, and business partners (who may be assisting with the administration of Lilly Cares and the Lilly Cares
Patient Assistance Program (“Program”)).

The categories of health information we collect will depend on how you interact with our services and the information you choose to
provide. We may collect:
• Health conditions, treatments, diseases, or diagnosis • Reproductive or sexual health information
• Social, psychological, behavioral, and medical interventions • Biometric data
• Health-related surgeries or procedures • Genetic data
• Use or purchase of prescribed medication • Data that identifies a consumer seeking health care services
• Bodily functions, vital signs, symptoms, or measurements of • Prescription and medical health insurance benefits
other types of consumer health data information
• Diagnoses or diagnostic testing, treatment, or medication • Other information that may be used to infer or derive data
related to the above or other health information.
With your consent, we may use the health information we collect for the following purposes, as further described in our privacy
statements:
• Providing services and support. • Security and protection of rights.
• Analytics and improvement. • Legal proceedings and obligations.
• Customization and personalization. • General business and operational support.
• Marketing and advertising.
We do not sell or share your health information with third parties without your consent or authorization. We may disclose health
information to entities or persons that work as processors on our behalf to provide you with services you request, including
administration of the Program.

We may use and save your personal information and health information to meet legal or regulatory obligations that are in our
legitimate interest, to fulfill legitimate and lawful business purposes (consistent with the charitable purposes of Lilly Cares), in
accordance with our record retention policies and applicable laws and regulations, and to respond to lawful requests by public
authorities, including to comply with national security or law enforcement requests.

Some of this personal information may be considered sensitive under applicable laws, such as information about your health or
medical diagnosis and demographic information collected in some circumstances, such as race, ethnic origin, and sexual orientation.
We may process your sensitive Personal Information with your consent, or as otherwise permitted by law.

Upon verification, you have rights with respect to the collection, use, and storage of your information. These rights may include access
to your information and how it is being used or shared, the right to correct, delete, or limit use of your information or to withdraw
consent for us to collect and use your information. There may be certain exceptions and limitations that apply to your request including
the right to have your information transmitted to another entity or person in a machine-readable format. To exercise your rights, you or
your authorized representative may submit a request to [email protected] or 1-800-Lilly-Rx (1-800-545-5979) (which will respond
to the request on behalf of Lilly Cares and the above-referenced entities). You will not be discriminated against for exercising any of
your rights. You may be entitled, in accordance with applicable law, to appeal a refusal to take action on your request. To do so, please
contact us by using one of the methods listed here or in How to Contact Us section of the online Privacy Statement.

If you wish to raise a complaint on how we have handled your personal information, you can contact the Eli Lilly and Company Global
Privacy Office and Data Protection Officer at [email protected], who will investigate the matter (on behalf of Lilly Cares and the
above-referenced entities). If you are not satisfied with our response or have any concerns about how your data is being processed,
you can register a complaint with a relevant regulatory authority (e.g., a Data Protection Authority (DPA) or Attorney General).

Lilly Cares Foundation Patient Assistance Program | PO BOX 501847 | San Diego, CA 92150
Phone: 1-800-545-6962 | Fax: 1-844-431-6650 | www.lillycares.com
PP-AP-US-0672 03/2025 © Lilly Cares® Foundation 2025. All rights reserved. Page 3 of 9
Patient Information Section
Please fill out all fields on this page. If your application isn’t complete,
it might delay your enrollment in the Lilly Cares Program.
v4

First Name Middle Initial Last Name

Address

City State ZIP Code

Date of Birth (MM/DD/YYYY) Phone Number (optional)1 Where would you like your medication delivered?3
To my home
To my healthcare provider’s office

1
By providing your phone number and signing this form, you agree to receive automated phone and text messages2. These notifications may include updates on
enrollment status or medication shipments. Your phone number is not mandatory for applying to the Program. Message and data rates may apply. You can opt
out by calling 1-800-545-6962. Infused medications are not eligible for automated messages.
2
Do NOT report product complaints or adverse events (like side effects) by text message. To report these, please call The Lilly Answers Center at 1-800-LillyRX
(1-800-545-5979).
3
Consult with your healthcare provider to confirm delivery location. Infused medications are not eligible for home delivery.

Patient Income Information

Number of people in your household Annual Household Income before taxes4, 5
Including you and Include wages, Social Security payments, disability and/or unemployment
all family members. benefits, pensions, and any other income of yourself and those in your household.5

4
Enter 0 for no household income.
5
When processing your application, you may be contacted by Lilly Cares to provide documentation showing your income.

Patient Insurance Information

Has your employer, insurance company, or their appointed representative directed you to seek enrollment in this program as a
requirement of your drug coverage plan? This does not include your healthcare provider or their office, specialty pharmacy, or a
family member.
No Yes
What type of health insurance do you have? (Check all that apply) 6
6
When processing your application, a benefits verification will be conducted. Insurance documentation may be requested.
I do not have health insurance
Medicare Other Insurance Type
Medicare Part D 7
Medicaid
Medicare Part B without supplemental/secondary insurance 8
VA or Military
Medicare Part B with supplemental/secondary insurance 8
Private Insurance (excluding Medicare Part D) 9
Medicare Advantage Plan
For Group 4 Medications, has your insurance denied coverage for the prescribed product?
No Yes - If yes, please include documentation. For details, visit: https://www.lillycares.com/assets/pdf/insuranceverification.pdf
7
An insurance card for Medicare Part D Prescription Drug Plans (PDP) usually includes a reference to "Medicare Rx" or "PDP" on the front or back of the card.
8
For example, Medigap, Medicare Advantage, employer private insurance.
9
For example, employer-sponsored plan and health insurance marketplace plan.

Lilly Cares Foundation Patient Assistance Program | PO BOX 501847 | San Diego, CA 92150
Phone: 1-800-545-6962 | Fax: 1-844-431-6650 | www.lillycares.com
PP-AP-US-0672 03/2025 © Lilly Cares® Foundation 2025. All rights reserved. Page 4 of 9
Patient Information Section
We encourage you to choose an answer for the next 2 questions right now,
but if you don't, it won’t delay your application to the Lilly Cares Program.
v4
Patient Authorization for Automatic Prescription Refills (“Auto-refill”)
If your prescription allows refills, Lilly Cares can automatically fill your medication when you are due for a refill. If you’ve provided
your cell number, we will send you a text message letting you know when your medication has shipped. When you have zero
refills remaining, we will contact your healthcare provider for a prescription renewal before your next refill due date. Auto-refills
will stop at the end of your program enrollment period or when your prescription has no more renewals.
If you no longer need the medication or to opt out of auto-refills, contact Lilly Cares at 1-800-545-6962. Infused medications
are not eligible for auto-refills.

Yes, automatically fill my medication when I am due for a refill.

No, do not automatically refill my medication. I will call Lilly Cares when I am due for a refill.

Patient Authorization to Speak with Authorized Representative

You may provide the names of one or more people with whom you authorize Lilly Cares to speak on your behalf about this
application or your participation in the Lilly Cares Program. These people can provide or receive your personal information as
necessary until the end of your enrollment period unless you request their authority be terminated prior to then.

Yes, I’d like to authorize a person to speak on my behalf.

No, I do not want anyone speaking to Lilly Cares on my behalf.

If you've opted "yes", please provide the name of at least 1 authorized representative below. By providing the name(s) below,
you certify that individuals are aware and agree that you will provide their name to Lilly Cares for the purpose of serving as your
authorized representative.

You can change or remove Authorized Representative(s) at any time by calling Lilly Cares at 1-800-545-6962.

Name of Authorized Representative 1 (Please print)

Relationship to Patient (Please print)

Family Member/Caregiver Other, please specify

Name of Authorized Representative 2 (Please print)

Relationship to Patient (Please print)

Family Member/Caregiver Other, please specify

Lilly Cares Foundation Patient Assistance Program | PO BOX 501847 | San Diego, CA 92150
Phone: 1-800-545-6962 | Fax: 1-844-431-6650 | www.lillycares.com
PP-AP-US-0672 03/2025 © Lilly Cares® Foundation 2025. All rights reserved. Page 5 of 9
Patient Certification Agreement v4
I understand that:
• I understand that I or my healthcare provider’s office is submitting this application to see if I qualify for assistance with my
Eli Lilly and Company medications through the Lilly Cares Foundation, Inc. (“Lilly Cares”). I understand that before Lilly Cares
can assist me, Lilly Cares may need to collect, use, and share information about me. When I sign below, I am authorizing any
pharmacy, healthcare provider, and/or others who are in possession of my personal information, including protected health
information (PHI), to share such information about me with Lilly Cares, Eli Lilly and Company, and its affiliates worldwide
including their authorized employees, agents, contractors, vendors, subsidiaries, and business partners who may be assisting
with the administration of Lilly Cares, including health information. In addition, I understand and am authorizing the sharing,
use and disclosure of my information, inclusive of health information, for the purposes of operating Lilly Cares as explained in
the Privacy Notice section above.
• Lilly Cares will decide if I qualify for the Lilly Cares Patient Assistance Program (“Program”). I understand that my application
might not be approved. Lilly Cares may change or end the Program, or terminate my enrollment in the Program, at any time.
• Lilly Cares does not charge a fee to apply for participation in the Program. I am not required to use a third party who
charges a fee to help with my enrollment, and if I use a third party who charges a fee to help with my enrollment or refills of my
medication, this money is not paid to Lilly Cares.
• If my application is approved, my approval letter will tell me when my enrollment will expire (generally in 12 months or at the
end of the calendar year for those with Medicare Part D). After my enrollment expires, I will need to reapply to the Program.
• For infused medications, I must have received treatment within 180 days of application approval, if granted.
• If I do not sign or refuse to sign this form, I will not be eligible for the Program.
I certify (agree) that:
• I am a permanent resident of the United States, Puerto Rico, or U.S. Virgin Islands.
• My application is complete and accurate. I have been truthful about my insurance coverage and income.
• I meet the Program eligibility criteria, including income and insurance coverage requirements, as shown on page 1 of this
application.
• I will promptly provide documentation supporting the information I have provided in this application (e.g., income verification
documents, pharmacy and medical health insurance benefit documents) if such documentation is requested by Lilly Cares.
Failure to promptly provide complete and accurate documentation when requested may result in immediate termination of
application review or removal from the Program if application has already been approved.
• I authorize the Lilly Cares Program representatives to obtain a consumer report about me in conjunction with my application.
Lilly Cares may use my name, date of birth, and address to obtain my consumer report including, but not limited to,
information regarding my household size and income. My consumer report will be used to estimate my household income as
part of the process to decide if I am eligible for the Program. This inquiry will not impact my credit score. Upon request, Lilly
Cares will provide me the name and address of the consumer reporting agency that provides the credit information. I may
call Lilly Cares at 1-800-545-6962 for this information. I understand Lilly Cares may request proof of my annual income and a
consumer report as a requirement for enrollment in the Lilly Cares Program.
• I authorize the Lilly Cares Program representatives to use my name, date of birth, and address to conduct a manual or electronic
benefits investigation of any applicable pharmacy and medical health insurance benefits in connection with this application. I
understand Lilly Cares may request proof of these benefits as a requirement for enrollment in the Lilly Cares Program.
• If my application is approved:
I will notify Lilly Cares of changes to my income or insurance status.
 I will not submit any claim for reimbursement to any third party or government insurer for any product provided to me
through the Lilly Cares Program.
 If I have Medicare Part D coverage, I will not seek to have the cost/value associated with the medication I receive
through the Program counted as out-of-pocket costs for prescription drugs.
If I have Medicare Part D coverage, I will inform my Part D Plan about my enrollment in Lilly Cares.
I will not sell, trade, or transfer any medication I receive through the Program.
If directed by provider, I consent to medication being shipped to provider.

Name of Patient (Please Print)

SIGNATURE OF PATIENT OR LEGAL GUARDIAN (REQUIRED) Date (MM/DD/YYYY)

Please fill out all fields and sign this form. If you don’t, it might delay your enrollment in the Lilly Cares Program.

Lilly Cares Foundation Patient Assistance Program | PO BOX 501847 | San Diego, CA 92150
Phone: 1-800-545-6962 | Fax: 1-844-431-6650 | www.lillycares.com
PP-AP-US-0672 03/2025 © Lilly Cares® Foundation 2025. All rights reserved. Page 6 of 9
Health Insurance Portability and Accountability Act
(HIPAA) Authorization v4

I consent to the sharing, use, and receipt of information about me, as described:
I understand that I or my healthcare provider’s office is submitting this application to see if I qualify for assistance with my Eli Lilly
and Company medications through the Lilly Cares Foundation, Inc. (“Lilly Cares”). I understand that before Lilly Cares can assist
me, Lilly Cares may need to collect, use, and share information about me. When I sign below, I am authorizing any pharmacy,
healthcare provider, and/or others who are in possession of my personal information, including health information, and protected
health information (PHI), to share such information about me with Lilly Cares, Eli Lilly and Company and its affiliates worldwide
including their authorized employees, agents, contractors, vendors, subsidiaries and business partners who may be assisting
with the administration of Lilly Cares (“Receiving Entities”). In addition, I understand and am authorizing the Receiving Entities to
share, use, and disclosure of my information for the purposes of operating the program.

The Receiving Entities may receive, share, and use the following information:
• Information in this application.
• Information about your medical conditions, treatment, current and future medications.
• Information about your health insurance or benefits (prescription and medical), including how much coverage you have.
• Other information the Receiving Entities may obtain to operate Lilly Cares.
• The Receiving Entities may share your information with your healthcare providers and pharmacists.
• Your healthcare providers and pharmacists may share your information with the Receiving Entities.

The Receiving Entities may share your information for the following purposes:
• To review your application to determine your eligibility and to contact you or your healthcare provider, if necessary, for that review.
• To help operate Lilly Cares and for the Receiving Entities’ internal purposes involving other patient assistance and charitable
programs.
• To your pharmacies and healthcare providers relating to your participation in the Lilly Cares Program, including personal
information and information about your prescription medications.
• To learn how much of your Eli Lilly and Company medication is covered by your insurance.
• Track use of medication.
• To measure program performance and make program improvements.
• We only ask for and share the PHI that we need to operate the Program. We do not ask for any PHI that we don’t need, but we
may receive some in health records sent to us.

By my signature below, I also agree to the following:

• You don’t have to give permission to share your PHI with Lilly Cares, but we may not be able to assist you without it.
• After your PHI has been shared, it may no longer be covered by federal and state privacy laws (such as HIPAA), and it may
be shared again.
• I understand that Program representatives can contact me to collect any additional information needed to provide these
services to me.
• This authorization allows those who rely on it to release my PHI for 3 years from the date I have signed it unless I am a
resident of Maryland, Maine or Montana, in which case the permission will last for 1 year from the date of signature.
• I understand that I can cancel my consent at any time by sending a written notice to Lilly Cares at the address on this
application. If I cancel my consent, I will no longer qualify for the Lilly Cares Program. My healthcare providers will no longer
share my PHI with the Receiving Entities after the date that the Receiving Entities receive and process my cancellation letter,
but this will not affect information or disclosures shared before that time. Additionally, once my cancellation is received and
processed by the Receiving Entities, my participation in the Lilly Cares Program will be terminated, and after my participation
is terminated, the Receiving Entities will only maintain and use my information for legal and regulatory purposes.
• I have the right to receive a signed copy of this HIPAA authorization or ask my healthcare provider for a copy.
Name of Patient (Please Print)

SIGNATURE OF PATIENT OR LEGAL GUARDIAN (REQUIRED) Date (MM/DD/YYYY)

Please fill out all fields and sign this form. If you don’t, it might delay your enrollment in the Lilly Cares Program.

End of Patient Section

Lilly Cares Foundation Patient Assistance Program | PO BOX 501847 | San Diego, CA 92150
Phone: 1-800-545-6962 | Fax: 1-844-431-6650 | www.lillycares.com
PP-AP-US-0672 03/2025 © Lilly Cares® Foundation 2025. All rights reserved. Page 7 of 9
 Healthcare Provider
(doctor or nurse) to fill Healthcare Provider/Prescriber Section
Confirmations and Agreements
this section out. v4
By signing below, I (the “Prescriber”) certify to the following statements:
• The information provided is accurate to the best of my knowledge.
• I am disclosing this information for treatment purposes as well as other medical information that may be disclosed, including medical records of the patient provided in the
Healthcare Provider/Prescriber Section (“Patient”), to the Lilly Cares Foundation, Inc. (“Lilly Cares”), Eli Lilly and Company, and its affiliates worldwide including their employees,
agents, vendors, business partners, and Program representatives who may be assisting with the administration of Lilly Cares for the purpose of assessing whether the Patient
qualifies for the Lilly Cares Patient Assistance Program (“Program”) through the duration of the Patient’s therapy. Prior to signing this form, I have ensured the Patient is aware
of, has consented to, and has directed my disclosure of their information to Lilly Cares so that Lilly Cares may contact the Patient to further enable services for those purposes
and that such consent and direction applies to disclosures made through the duration of the Patient therapy.
• I am licensed, will comply with and abide by my state practitioner dispensing laws for authorized prescribers in the state in which I am prescribing, receiving, storing, and
dispensing the medication identified on this application to the Patient listed in this application. I also will comply with applicable laws related to disposal of, and will properly
dispose, unused medication.
• I prescribed the above-referenced medication (the “Medication”) to the Patient listed on this form based on my independent clinical judgment that treatment with this
Medication for the Patient is medically necessary.
• Any ICD-10 code I have provided is accurate, and for an FDA-approved indication and/or compendia use for the Medication I have prescribed for this Patient.
• To the best of my knowledge the Patient meets the financial need, insurance, and residency requirements of the Lilly Cares Program. If I become aware the Patient may
no longer meet the criteria for the program, I agree to notify Lilly Cares.
• I have not received and will not seek reimbursement or payment for all or any part of the benefit received by the Patient through Lilly Cares.
• I acknowledge and agree that any Medication provided by Lilly Cares for this Patient cannot be resold, nor offered for sale, trade, or barter, nor returned for credit (each
a “Financial Use”) I certify that I will not make or permit any Financial Use of any Medication provided by Lilly Cares.
• If the Patient has insurance, a claim or request has been made to that insurer, that claim has been denied, an appeal to the insurer has been completed and I have
received a denial for that appeal as required by the program guidelines.
• If a retroactive insurer policy change allows for reimbursement of product already supplied at no charge, I agree not to seek reimbursement for that product, and to notify
Lilly Cares of the availability of reimbursement. If I receive any subsequent reimbursement from any source for product supplied without cost by Lilly Cares, I will notify Lilly
Cares and will follow Lilly Cares instructions regarding those funds. I acknowledge that I am not permitted to receive financial benefit from product provided by Lilly Cares.
• If I elect to receive Medication from Lilly Cares under the Proactive Provision program, I will complete any requested documentation, will notify Lilly Cares if any product
is not administered to the applicable enrolled Patient and will return the product to Lilly Cares or appropriately destroy the product at the facility (if requested by Lilly
Cares) and submit documentation to Lilly Cares confirming that the product has been appropriately destroyed.

I understand:
• Lilly Cares will only provide Medication to the extent consistent with its tax-exempt purposes, qualified under Section 170(e)(3) of the Internal Revenue Code, and
authorized by Lilly Cares policies, which may include the providing of Medication to me (as the eligible Patient’s healthcare provider) for the sole purpose of caring for
the ill, needy, indigent and/or infants in the United States.
• Lilly Cares may change, terminate, suspend participation, limit enrollment, or recall/discontinue Medications in the Program without prior notice.
• Lilly Cares does not charge a fee to apply for participation in the Program. Patient is not required to use a third party that charges a fee to help Patient with enrollment,
and if Patient uses a third party that charges a fee to help with their enrollment or refills of Medication, this money is not paid to Lilly Cares.
• I am under no obligation to purchase or prescribe any Eli Lilly and Company drug to participate in this program and I certify that I have not received, and I understand
that I will not receive any benefit from any Program representatives for prescribing an Eli Lilly and Company drug.
• Program representatives are not responsible for filing any insurance claim.
• The information provided will be subject to potential reviews by Lilly Cares.
• Fax communications sent to a single number may split to multiple Receiving Entities for the purpose of operating the Program.
• I am to provide the Patient a signed copy of their HIPAA authorization upon request.
• If I elect to receive Medication from Lilly Cares under the Proactive Provision program and I do not return or destroy the product provided and not used for the applicable
enrolled Patient, I will be billed for the product (or demand for equivalent payment in method determined appropriate by Lilly Cares to ensure that healthcare provider
does not benefit from product provided by Lilly Cares) and I will be responsible for payment of the bill. Please contact Lilly Cares at 1-800-545-6962 for assistance with
product returns.

My signature below attests to my understanding and agreement to the above Program requirements.
Patient Name (Please print) Date of Birth (MM/DD/YYYY) Medication(s) Requested Specify Formulation Type

Office Contact Name Office Contact Phone Office Contact Fax Date (MM/DD/YYYY)

Prescriber Name (Please print) PRESCRIBER SIGNATURE (REQUIRED)

Please indicate the method for submitting a prescription to Lilly Cares. Please read carefully and submit prescription via one method only.
Electronic prescription: select Neovance Specialty Pharmacy (NPI 1780811125) in the eRx software.
Fax prescription to 1-844-431-6650 using the optional prescription template on page 9 of the application, resources on lillycares.com, or provider generated prescription.

DO NOT complete page 9 of the application if submitting an electronic prescription or faxing a provider-generated prescription.
Infused ONCOLOGY ICD 10 Code Infused ONCOLOGY Product Replacement Request
Required for Alimta®, Cyramza®, & Erbitux® ONLY: A prescription is not required for product replacement
(Infused oncology medications must be used only for an FDA approved   Alimta   Cyramza   Erbitux
indication or compendia-supported use.)
Administration Date Dosage # of Vials Vial Size

Please fill out all fields and sign this form. An incomplete form may delay the patient's enrollment in the Lilly Cares Program.

Lilly Cares Foundation Patient Assistance Program | PO BOX 501847 | San Diego, CA 92150
Phone: 1-800-545-6962 | Fax: 1-844-431-6650 | www.lillycares.com
PP-AP-US-0672 03/2025 © Lilly Cares® Foundation 2025. All rights reserved. Page 8 of 9
 Healthcare Provider: DO NOT
complete if submitting an
Lilly Cares Prescription Template
Patient Information
electronic prescription or faxing Note: If the patient’s application is approved, medication will be delivered to the location selected by the patient. Please
a provider generated prescription
coordinate with your patient to ensure appropriate delivery location. Infused medications are not eligible for home delivery.
v4
New applications for Trulicity are temporarily not being accepted, except for limited medical exception cases. Visit lillycares.com/how-to-apply
for medical exception requirements and form. Lilly Cares will accept applications for re-enrollment of those currently enrolled for Trulicity.

Please fill out all fields. An incomplete form may delay the patient’s enrollment in the Lilly Cares Program.
Patient Name Date of Birth (MM/DD/YYYY)

Address City

State ZIP Code Phone Number Drug Allergies

Other Medications

Rx: I authorize Lilly Cares to act on my behalf for the purpose of transmitting this prescription to the appropriate pharmacy. To submit an
electronic prescription, please select Neovance Specialty Pharmacy (NPI 1780811125) in your eRx software.
Medication Strength Maximum Dose per Day

Directions (Please print)

Are you prescribing insulin? If yes, select the prescribed insulin:

Yes No Vial (not available for Basaglar®, Humalog® U-200, Humalog® 50/50, Humulin® U-500, or Lyumjev™ U-200)
KwikPen® (not available for Humulin® R-100 units/mL)
Cartridge (only available for Humalog® 100 units/mL)

Refill # Quantity to be Dispensed (oncology medications are limited to a ONE-month supply)

4 Month (max) 3 Month 2 Month 1 Month
Your state may require that prescriptions follow certain content requirements or use a particular form. Non-compliance with state-specific requirements will result in outreach
to the prescriber and may delay shipping of medication. By signing below, you certify that you are abiding by laws applicable to prescriptions and authorized prescribers in
the states in which you are prescribing. I authorize Lilly Cares to act on my behalf for the limited purposes of transmitting this order for prescription medication.

Select one: Dispense as written Substitution Brand Exchange Permitted

PRESCRIBER SIGNATURE Today's Date (MM/DD/YYYY)

Rubber stamps, signature by other office personnel for the prescriber, and computer-generated signatures will not be accepted.

Healthcare Provider Information

Healthcare Provider Name and Title (Please print) DEA # (as required)

State License # and State NPI #

Address City

State ZIP Code Phone Number Fax Number

Office Contact Name Office Contact Phone

Lilly Cares Foundation Patient Assistance Program | PO BOX 501847 | San Diego, CA 92150
Phone: 1-800-545-6962 | Fax: 1-844-431-6650 | www.lillycares.com
PP-AP-US-0672 03/2025 © Lilly Cares® Foundation 2025. All rights reserved. Page 9 of 9