[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-306842-105":53,"doc-detail-306842-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","lilly-cares-foundation-patient-assistance-program-application-patient-assistance-program-application","Lilly Cares Foundation Patient Assistance Program Application - Patient Assistance Program Application","","Lilly Cares Foundation, Inc. patient assistance program application form for qualifying patients seeking certain Eli Lilly and Company medications at no cost. The document explains the program purpose, available medication groups and special handling for infused treatments, eligibility requirements tied to U.S. residency, household income limits and insurance restrictions, and exclusions such as Medicaid, LIS, VA benefits, and alternative funding programs. It also provides annual adjusted household income thresholds based on Federal Poverty Level guidelines and contact details.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/lilly-cares-foundation-patient-assistance-program-application-patient-assistance-program-application/306842/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/lilly-cares-foundation-patient-assistance-program-application-patient-assistance-program-application/306842.png","ImageObject",442,249,{"name":88,"@type":89},"\tWilliam","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-25","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":35},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who is eligible to apply for the Lilly Cares Patient Assistance Program?","Question",{"text":108,"@type":109},"Qualifying patients must have a healthcare provider prescription for an eligible Lilly medication, meet U.S. residency requirements, and satisfy household income guidelines. Applicants must also meet insurance and benefit exclusions described in the form.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What medications and medication groups are included in the program?",{"text":113,"@type":109},"The form lists medications in Group 1 through Group 4, including tablets, injections, and certain infused medications. It also notes that infused medication handling differs for insurance and treatment setting requirements.",{"name":115,"@type":106,"acceptedAnswer":116},"How are annual adjusted household income limits determined?",{"text":117,"@type":109},"Income thresholds are shown as dollar amounts by household size and medication group, calculated using Federal Poverty Level (FPL) guidelines. The form states limits may change annually and references current 2026 FPL guidelines.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},306842,1789841758,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":35,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":135,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":125,"read_time":76},5909887254083,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","LILLY CARES® FOUNDATION, INC.  \nPatient Assistance Program Application  \nThe 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.  \nAn electronic application is available at [www.lillycares.com](www.lillycares.com) and is recommended to reduce paperwork and potential delays.  \nMedications Provided by the Lilly Cares Program  \n\n| Group 1 Medications\u003Cbr>• Cialis® (tadalafil) tablets\u003Cbr>• Emgality® (galcanezumab-gnlm) injection\u003Cbr>• Forteo® (teriparatide injection)\u003Cbr>• Reyvow® (lasmiditan)\u003Cbr>• Trulicity® (dulaglutide) injection | Group 2 Medications\u003Cbr>• Basaglar® (insulin glargine injection)\u003Cbr>• Humalog® (insulin lispro injection)\u003Cbr>• Humulin® (human insulin)\u003Cbr>• Lyumjev® (insulin lispro-aabc) injection | Group 3 Medications\u003Cbr>• Ebglyss® (lebrikizumab-lbkz) for injection\u003Cbr>• Omvoh® (mirikizumab-mrkz)\u003Cbr>infusion†\u003Cbr>• Omvoh® (mirikizumab-mrkz) injection\u003Cbr>• Olumiant® (baricitinib) tablets\u003Cbr>• Taltz® (ixekizumab) injection | Group 4 Medications\u003Cbr>• Cyramza® (ramucirumab) injection†\u003Cbr>• Erbitux® (cetuximab) injection†\u003Cbr>• Inluriyo ™ (imlunestrant) tablets\u003Cbr>• Jaypirca® (pirtobrutinib) tablets\u003Cbr>• Kisunla® (donanemab-azbt)\u003Cbr>injection†\u003Cbr>• Retevmo® (selpercatinib) tablets\u003Cbr>• Verzenio® (abemaciclib) tablets † indicates infused medication |\n| --- | --- | --- | --- |\n\nTo qualify, you must meet all the requirements listed below:  \n• Your healthcare provider has prescribed a qualifying Lilly medication.  \n• You are a permanent resident of the United States,(inclusive of Puerto Rico and the U.S. Virgin Islands) .  \n• You meet the household income guidelines for the program (shown below) .  \n• You are not enrolled in Medicaid, full Low-Income Subsidy (LIS,“Extra Help”), or Veterans (“VA”) Benefits.  \n• The following applies to you regarding your insurance coverage:  \n○ Medication Group 1, 2, and 3 Either:  \n1) 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) .  \n○ Medication Group 4 Either:  \n1) 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](https://www.lillycares.com/assets/pdf/insuranceverification.pdf).  \n• 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* .  \n• If applying for an infused medication, the treatment must be provided in an outpatient setting.  \n• 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.  \nAnnual Adjusted Household Income Limit  \nThe 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 2026 FPL guidelines. Please visit [www.aspe.hhs.gov/pove](www.aspe.hhs.gov/pove)rty for t","cbCaioX2euZpSWdL","https://ap.wps.com/l/cbCaioX2euZpSWdL","pdf",592536,9,"English","# Patient Assistance Program Application\n## Lilly Cares Program Overview\n## Medications Provided by the Program\n## Eligibility Requirements\n## Annual Adjusted Household Income Limits\n## Contact Information","[{\"question\":\"Who is eligible to apply for the Lilly Cares Patient Assistance Program?\",\"answer\":\"Qualifying patients must have a healthcare provider prescription for an eligible Lilly medication, meet U.S. residency requirements, and satisfy household income guidelines. Applicants must also meet insurance and benefit exclusions described in the form.\"},{\"question\":\"What medications and medication groups are included in the program?\",\"answer\":\"The form lists medications in Group 1 through Group 4, including tablets, injections, and certain infused medications. It also notes that infused medication handling differs for insurance and treatment setting requirements.\"},{\"question\":\"How are annual adjusted household income limits determined?\",\"answer\":\"Income thresholds are shown as dollar amounts by household size and medication group, calculated using Federal Poverty Level (FPL) guidelines. The form states limits may change annually and references current 2026 FPL guidelines.\"}]","Lilly Cares Foundation Patient Assistance Program Application - Patient Assistance Program Application | PDF"]