[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-306840-105":53,"doc-detail-306840-en":127},{"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":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","trulicity-medical-exception-request-form","Trulicity - Medical Exception Request Form","","Trulicity Medical Exception Request Form collects information required for Lilly Cares Foundation Patient Assistance Program enrollment for patients with special medical circumstances. The patient’s prescriber must complete and fax the form with a Lilly Cares application. Eligibility criteria require type 2 diabetes mellitus, current or prior Trulicity use within 12 months, and age over 10, plus additional treatment failure or qualifying clinical conditions checked by the prescriber.",{"@graph":63,"@context":119},[64,80,102],{"@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/trulicity-medical-exception-request-form/306840/",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/trulicity-medical-exception-request-form/306840.png","ImageObject",442,249,{"name":88,"@type":89},"Connor ","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-27","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",13,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Who must complete and submit the Trulicity Medical Exception Request Form?","Question",{"text":109,"@type":110},"The patient’s healthcare provider must complete the form and fax it along with a Lilly Cares application. The provider must check all applicable boxes for eligibility criteria.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What are the basic eligibility criteria for medical exception consideration?",{"text":114,"@type":110},"The patient must have type 2 diabetes mellitus, be on Trulicity currently or within the past 12 months, and be over age 10. The provider must also document required prior treatment attempts within the past 12 months.",{"name":116,"@type":107,"acceptedAnswer":117},"What additional conditions may qualify a patient under this form?",{"text":118,"@type":110},"At least one additional condition must apply, such as prior inadequate response or intolerance/contraindication to metformin, need for combination therapy with A1C 7.5% or greater, or established cardiovascular disease or multiple cardiovascular risk factors.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},306840,1790195972,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"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":140,"read_time":4},687207022233,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","p: 1-800-545-6962 | f: 1-844-431-6650 [www.lillycares.com](www.lillycares.com)  \nTrulicity® Medical Exception Request Form  \nLilly Cares Foundation Patient Assistance Program is currently not accepting new applications for Trulicity. However, Lilly Cares will accept new applications for patients in special medical circumstances. In order to be considered for enrollment, the patient’s healthcare provider must complete and fax this form along with a Lilly Cares application. The patient must meet all other Lilly Cares eligibility requirements. This form is not to be used for currently enrolled patients who are re-enrolling for Lilly Cares.  \nThe patient must meet ALL of the following criteria, and prescriber must check all boxes that apply.  \n􀁆 Diagnosed with type 2 diabetes mellitus  \n􀁆 On Trulicity currently or within past 12 months  \n􀁆 Over age 10  \n􀁆 Within past 12 months previously tried and failed at least one other GLP-1 receptor agonist after at least 3 months on each therapy  \nAND at least one of the following:  \n􀁆 Has previously tried metformin and had an inadequate treatment response, intolerance, or has a contraindication to metformin  \n􀁆 Requires combination therapy AND has an A1C of 7.5% or greater  \n􀁆 Has established cardiovascular disease or multiple cardiovascular risk factors  \nPatient Name:  DOB:   \nPrescriber Name (print):  Office Phone:   \nI attest that the information on this form is true and correct. I understand that Lilly Cares Foundation is relying on this attestation in making its determination.  \nPrescriber signature:  Date:   \nIMPORTANT: This information is intended for the use of the person or entity to which it is addressed and may contain information that is confidential, the disclosure of which is governed by applicable law. If the reader of this information is not the intended recipient, or the authorized agent or individual responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this information is STRICTLY PROHIBITED. If you received this document in error, please notify us immediately and destroy the related document.  \nPP-AP-US-0650 10/2024 © Lilly Cares® Foundation 2024. All rights reserved.","cbCairA2LgRQIZ1B","https://ap.wps.com/l/cbCairA2LgRQIZ1B","pdf",79018,"English","# Eligibility Criteria\n## Required Prescriber-Checked Conditions\n## Patient and Provider Information","[{\"question\":\"Who must complete and submit the Trulicity Medical Exception Request Form?\",\"answer\":\"The patient’s healthcare provider must complete the form and fax it along with a Lilly Cares application. The provider must check all applicable boxes for eligibility criteria.\"},{\"question\":\"What are the basic eligibility criteria for medical exception consideration?\",\"answer\":\"The patient must have type 2 diabetes mellitus, be on Trulicity currently or within the past 12 months, and be over age 10. The provider must also document required prior treatment attempts within the past 12 months.\"},{\"question\":\"What additional conditions may qualify a patient under this form?\",\"answer\":\"At least one additional condition must apply, such as prior inadequate response or intolerance/contraindication to metformin, need for combination therapy with A1C 7.5% or greater, or established cardiovascular disease or multiple cardiovascular risk factors.\"}]","Trulicity - Medical Exception Request Form | PDF",1789841755]