Fillable FOUNDATION Patient Assistance Program Oncology Application LILLY CARES

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FOUNDATION Patient Assistance Program Oncology Application LILLY CARES

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Lilly Cares Foundation Patient Assistance Program | PO Box 13185 | La Jolla, CA
92039
Phone: 1-800-545-6962 | Fax: 1-888-242-6230 | www.lillycares.com
PP-AP-US-0487 03/2022 © Lilly USA, LLC 2022. All rights reserved.
LILLY CARES
®
FOUNDATION Patient Assistance Program
Oncology Application
The 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. This Application Form is for patients who would like to apply to
receive the available medication(s) at no cost through the Program.
Please complete and submit by fax or mail, or apply online at www.lillycares.com.
What medications are provided by the Lilly Cares Program?
Alimta
®
(pemetrexed for injection) Cyramza
®
(ramucirumab) injection Erbitux
®
(cetuximab) injection
Portrazza
®
(necitumumab) injection Retevmo
®
(selpercatinib) capsules Verzenio
®
(abemaciclib) tablets
Who qualifies for the Lilly Cares Program?
To qualify, you must meet the requirements listed below:
• You are a permanent, legal resident of the United States, Puerto Rico or U.S. Virgin Islands.
• You have been prescribed one of the Lilly Oncology medications listed above for an FDA-approved indication or compendia use.
• One of the following applies to you: 1) You have no insurance, 2) your insurance has denied a claim for coverage and one appeal for a
prescribed Lilly medication listed above, or 3) you have Medicare Part D, or 4) you have Medicare Part B but have no supplemental or
secondary insurance (e.g., private insurance offered by former employer, Medigap, Medicare Advantage).
• You are not enrolled in Medicaid, full Low-Income Subsidy (LIS, “Extra Help”) or Veterans (VA) Benefits.
• The treatment must be provided in an outpatient setting. If your healthcare provider is seeking replacement product for infused medication that
you have already received, you must have received treatment within the last 180 days.
• Your Annual Household Income is at or below 500% of the Federal Poverty Guidelines (See table below).
Annual Adjusted Gross Income Limit
Based on 2022 Federal Poverty Level (FPL) Guidelines. See www.aspe.hhs.gov/poverty
for more information.
Number of persons living in your household
(Including you and all family members)
1 2 3 4 5 6
Annual household income before taxes
(Include wages, Social Security payments, disability
and/or unemployment benefits, pensions, and any
other income of yours and those in your household)
$67,950 $91,550 $115,150 $138,750
$162,350 $185,950
* 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.
How do I apply?
1.
Complete the Patient Section (pages 2-4); sign the Patient Certification on page 4.
2.
Ask your healthcare provider to complete the Healthcare Provider/Prescriber Section (page 5), sign the prescription (page 5) and
Healthcare Provider’s/Prescriber’s Confirmations and Agreements (page 6), and return.
Non-Medicare Patients: If you have insurance that does not cover the medication, you must submit documentation that your insurance
company has denied both the initial claim and one appeal. Your healthcare provider or specialty pharmacy may be able to help you
obtain this documentation. Your healthcare provider or specialty pharmacy may contact the Lilly Cares Oncology Support Center at 1-
866-472-8663 with questions.
3.
Fax or mail the completed and signed application to Lilly Cares at 1-888-242-6230 or PO Box 13185, La Jolla, CA 92039.
After we review your application, we will send a letter to you and your healthcare provider notifying you of whether you qualify for the
Lilly Cares Program. If you qualify for Lilly Cares:
• You will be enrolled for 12 months. If you are Medicare Part D patient, you will be enrolled through the end of the calendar year.
• The medication will either be shipped to your home or to your healthcare provider. We will contact you to schedule home shipment, if
applicable.
If you do not qualify for Lilly Cares, a notice will be sent to you and your healthcare provider.
Page 2 of 6
Lilly Cares Foundation Patient Assistance Program
|
PO Box 13185 | La Jolla, CA 92039
Phone: 1-800-545-6962 | Fax: 1-888-242-6230 | www.lillycares.com
PP-AP-US-0487 03/2022 © Lilly USA, LLC 2022. All rights reserved.
PATIENT SECTION
Patient Information [REQUIRED] Please print clearly.
Patient Name: (Last) (First)
(MI)
Date of Birth:
(Month/Day/Year)
Preferred
Phone:
( ) -
Address:
City:
State: Zip:
Patient Income Information [REQUIRED]
(including you and all family members):
Annual Household Income before taxes
(Include wages, Social Security payments, disability and/or
unemployment benefits, pensions, and any other income of
yourself and those in your household)*:
*When processing your application, Lilly Cares may contact you and require that you provide documentation showing your income.
Patient Insurance Information [REQUIRED]
Do you have insurance (check all that apply)?
☐ Medicaid
☐
Medicare Part B without supplemental/secondary
i*
☐ Medicare Part D
☐ VA or Military
☐ Medicare Part B with supplemental/secondary insurance*
☐ Private Insurance**
☐ None
☐ Other ________________________________
*e.g., Medigap, Medicare Advantage, Employer private insurance ** e.g., employer sponsored plan, Health Insurance Marketplace plan
PLEASE NOTE: Not providing ALL required information above will delay the processing of your application.
Text Message Notification of Approval for Verzenio and Retevmo
[OPTIONAL]
If your application is approved, we can send you text messages about the Program throughout your enrollment period. These text
messages are optional. You can participate in Lilly Cares without signing up for text messages.
W
hen you sign up for the text messages (by providing your cell phone number below), you must agree to the following conditions:
• 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
ca
rrier outages, or discontinued service.
• Be aware that anyone who can open or have access to your phone might see your text messages.
• If your mobile operator is not participating in this service, you will not receive messages.
• These text messages are NOT reminders to take your medication. You are responsible to take your medication as prescribed.
• 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).
To receive text messages, you must provide your cell phone number:
Authorization to Speak with Authorized Representative
[OPTIONAL]
You may provide the names of one or more people with whom you authorize Lilly Cares to speak with 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 you terminate their authority. Their authority will not automatically
terminate once we process your application. Their authority will terminate at the end of your enrollment period.
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.
1. Print Name of Authorized Representative 2. Print Name of Authorized Representative
You can remove Authorized Representative(s) at any time by calling Lilly Cares at 1-800-545-6962.
Page 3 of 6
Lilly Cares Foundation Patient Assistance Program
|
PO Box 13185 | La Jolla, CA 92039
Phone: 1-800-545-6962 | Fax: 1-888-242-6230 | www.lillycares.com
PP-AP-US-0487 03/2022 © Lilly USA, LLC 2022. All rights reserved.
Privacy Notice:
We may use and save your personal information to meet legal or regulatory obligations that are in the legitimate interest of Lilly Cares, to fulfill
legitimate and lawful business purposes in accordance with Lilly Cares’ 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.
We may transmit personal information about you to Lilly and its affiliates worldwide (who may be assisting with the administration of Lilly
Cares). These affiliates may in turn transmit personal information about you to other Lilly affiliates. Some of Lilly’s affiliates may be located in
countries that do not ensure the same level of data protection. Nevertheless, all of Lilly’s affiliates are required to treat personal information in
a manner consistent with this notice. To obtain additional information about privacy practices, including the basis for transfers and safeguards
in place for cross-border transfers of personal information, please contact privacy@lilly.com or visit https://www.lilly.com/privacy.
We provide reasonable physical, electronic and procedural safeguards to protect information we work with and maintain. We limit access to
your information to authorized employees, agents, contractors, vendors, subsidiaries, and business partners, or others who need such access
to information to carry out their assigned roles and responsibilities on behalf of Lilly Cares. Please be aware, although we try to protect the
information we work with and maintain, no security system can prevent all potential security breaches. We do not sell personal information.
Upon verification, you have the right to request information from us regarding how your personal information is being used and with whom that
information is being shared. You also have the right to request to see and get a copy of the personal information that we have about you,
request its correction or request its erasure/deletion.
There may be exceptions that apply to your request.
In limited circumstances, you may have the right to have your information transmitted to another entity or person in a machine-readable
format. You will not be discriminated against for exercising any of your rights.
To exercise your rights, you or your authorized representative may submit a request by contacting us using one of the methods listed below.
You may make any of the above requests by contacting us at:
Lilly Cares Foundation Patient Assistance Program
PO Box 13185
La Jolla, CA 92039
Phone: 1-800-545-6962
If you wish to raise a complaint on how we have handled your personal information, you can contact the Global Privacy Office and Data
Protection Officer at privacy@lilly.com who will investigate the matter for Lilly Cares.
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).
Page 4 of 6
Lilly Cares Foundation Patient Assistance Program | PO Box 13185 | La Jolla, CA 92039
Phone: 1
-800-545-6962 | Fax: 1-888-242-6230 | www.lillycares.com
PP
-AP-US-0487 03/2022 © Lilly USA, LLC 2022. All rights reserved.
PATIENT CERTIFICATION (AGREEMENT)
I
understand that:
• Lilly Cares will decide if I qualify for the 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 approved, my enrollment in the Program will expire at the end of the calendar year (if I am a Medicare Part D patient) or after 12 months. 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, legal 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) if such
documentation is requested by Lilly Cares. (Failure to promptly provide complete and accurate documentation when requested may result in immediate
t
ermination 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 as a requirement of enrollment in Lilly Cares.
• If my application is approved:
o I will notify Lilly Cares of changes to my income or insurance status.
o I will not submit any claim for reimbursement to any third party or government insurer for any product provided to me through the Program.
o 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.
o If I have Medicare Part D coverage, I will inform my Part D Plan about my enrollment in Lilly Cares.
o I will not sell, trade, or transfer any medication I receive through the Program.
I consent to the sharing, use, and receipt of information about me, as described:
I understand that I or my doctor’s office is submitting this application to see if I qualify for assistance with my Lilly oncology medications through Lilly Cares. I
understand that before Lilly Cares can assist me, Lilly Cares may need to collect, use, and share information about me. This information is requested in this
application. This information is called My Personal Information. It includes: My Protected Health Information (PHI), My financial information, and other
personal information about me.
My PHI may include:
• Any information related to my healthcare insurance or plan benefits, including coverage limits.
• Other information related to my health and treatment. This may include information that may be sensitive, relating to sexually transmitted diseases, mental
health conditions, and/or genetic testing.
• Information related to my health while I am in the Lilly Cares program, such as whether I’m staying on my medicine or treatment.
• Some information that may not be related to my Lilly oncology medication and is not requested by Lilly Cares. This information may be sent only because it is
part of my health care records.
I understand that by signing this form, I am permitting the following providers to release My Personal Information, including my PHI, to Lilly Cares
Program Representatives (defined below):
- My doctor’s office - My pharmacies - My healthcare plan or insurance company - Other providers
• Lilly Cares “Program Representatives” include the Lilly Cares Foundation, Inc., Eli Lilly and Company, Lilly USA, LLC, and their vendors, business
partners, and agents who may be assisting Lilly Cares. I understand that to provide the services for Lilly Cares, the Program Representatives may need to
s
hare My Personal Information with other Program Representatives involved with Lilly Cares, and with my doctor’s office or other healthcare providers,
including my insurance company or health plan or pharmacies, or other patient assistance and charitable programs.
• I further understand that the Program Representatives will use My Personal Information in the following manner:
o To review my application for the Lilly Cares program.
o To contact me or my doctor’s office or other of my healthcare providers, as necessary, to conduct such services.
o F
or purposes relating to the operation and administration of the Lilly Cares program, including measuring and tracking the quality of the services.
o To keep track of my use of Lilly oncology medicines provided by Lilly Cares.
• 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 also understand that the 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 1 year from the date I have signed it. I understand that I can withdraw it at any time by
sending a written notice to Lilly Cares at PO Box 13185 La Jolla, CA 92039. My withdrawal goes into effect once it is received by Lilly Cares. I also
understand that by withdrawing, I may not receive or I may stop receiving Lilly oncology medicines provided by Lilly Cares.
• 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 Lilly Cares. My healthcare providers will no longer share my PHI with the Receiving Entities after the date that the Receivi
ng
E
ntities 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 Lilly Cares will be terminated, and after my participation is terminated,
the Receiving Entities will only maintain and use my information for legal and regulatory purposes
Patient or Legal Guardian Signature: Date: _____________________
(SIGNATURE REQUIRED)
Patient Printed Name: _______________________________________________________________________________________
Page 5 of 6
Lilly Cares Foundation Patient Assistance Program | PO Box 13185 | La Jolla, CA 92039
Phone: 1
-800-545-6962 | Fax: 1-888-242-6230 | www.lillycares.com
PP
-AP-US-0487 03/2022 © Lilly USA, LLC 2022. All rights reserved.
HEALTHCARE PROVIDER/PRESCRIBER SECTION
Patient Information (all fields are required):
Date:
ICD.10:
Patient Name: Date of Birth:
Address: Phone:
City: State: Zip Code:
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.
Your state may require that prescriptions follow certain content requirements or use a particular form. 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.
Prescriber Signature:
Dispense as written
Substitution/brand exchange permitted
Rubber stamps, signature by other office personnel for the prescriber, and computer-generated signatures will not be accepted.
Healthcare Provider Information (all fields are required):
Complete this section for infused products only.
Infused Product Requested:
□ Alimta □ Cyramza □ Erbitux □ Portrazza
□
Product
Replacement
– Request product after dose is administered.
Date of Drug Administration Dosage # of Vials Vial Size Date of Drug Administration Dosage # of Vials Vial Size
□ Proactive Provision
– Please fill out only if r
equesting
product prior to administration
Vial Size/Strength: # of Vials: Dosing Schedule/Frequency:
Directions:
Complete this section for Verzenio
and Retevmo. This medication will be shipped to the patient's home.
Prescription for Verzenio
®
(abemaciclib) Tablets
Prescription for Retevmo™ (selpercatinib) Capsules
□ Verzenio: 50 mg 7-day blister pack (NDC: 0002-4483-54)
□ Retevmo: 80 mg 120-count bottle (NDC: 0002-2980-26)
□ Verzenio: 100 mg 7-day blister pack (NDC: 0002-4815-54)
□ Retevmo: 80 mg 60-count bottle (NDC: 0002-2980-60)
□ Verzenio: 150 mg 7-day blister pack (NDC: 0002-5337-54)
□ Retevmo: 40 mg 60-count bottle (NDC: 0002-3977-60)
□ Verzenio: 200 mg 7-day blister pack (NDC: 0002-6216-54)
Quantity: 1 month supply Refills (up to 1 year): _________ Quantity: 1 month supply Refills (up to 1 year): ___________
Directions: 1 tablet twice daily
Directions: ___________________________________________
Facility Name:
Facility Phone: Fax:
Prescriber Name:
(Circle: M.D. D.O. N.P. P.A. R.Ph. other: _____)
State License # and State: NPI #:
Address:
City: State:
Zip:
Office Contact Name:
Office Contact
Phone:
Page 6 of 6
Lilly Cares Foundation Patient Assistance Program | PO Box 13185 | La Jolla, CA 92039
Phone: 1
-800-545-6962 | Fax: 1-888-242-6230 | www.lillycares.com
PP
-AP-US-0487 03/2022 © Lilly USA, LLC 2022. All rights reserved.
H
ealthcare Provider’s/Prescriber’s Confirmations and Agreements:
By signing the below, I certify:
• The information provided is accurate to the best of my knowledge.
• The therapy is medically necessary. I also represent that I am disclosing this information for treatment purposes as well as other medical
information that may be disclosed, including medical records of the patient, the Lilly Cares Foundation, Inc., Eli Lilly and Company, Lilly USA, LLC
and their vendors, business partners, and agents (the “Program Representatives”) for the purpose of assessing whether the patient qualifies for the
Lilly Cares program through the duration of the patient’s therapy. I also certify that the patient is aware and has consented to my disclosure of their
information to Program Representatives so that Program Representatives may contact the patient to further enable these services.
• 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 prescribed the medication to
this patient based on my independent clinical judgment that treatment with this medicine for this patient is medically necessary.
• I have prescribed this patient a Lilly oncology medication for an FDA-approved indication and/or compendia use.
• To the best of my knowledge the patient meets the financial, 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.
• Any medication provided by Lilly Cares for this patient will not be resold, nor offered for sale, trade, or barter, or returned for credit.
• An appeal to the insurer has been completed and I have received a denial for that appeal.
I understand:
• Lilly Cares may change, terminate, suspend participation, limit enrollment, or recall/discontinue medications in the program without prior notice.
• I am under no obligation to purchase or prescribe any Lilly drug to participate in this program and I have not received, nor will I receive any benefit
from any Program Representatives for prescribing a Lilly drug.
• Program Representatives are not responsible for filing any insurance claim.
• The information provided will be subject to potential random reviews.
• Fax communications sent to a single number may split to multiple Receiving Entities for the purpose of operating the Program.
• If a retroactive insurer policy change allows for reimbursement of product already supplied at no charge, Lilly Cares will bill for the covered product,
and I agree to be responsible for payment of the bill.
• If I elect to receive medication from Lilly Cares under the Proactive Provision program, I certify that I will complete any requested documentation. I
will notify Lilly Cares if any product is not administered to the applicable enrolled patient and will return the product to Lilly Cares for destruction or
appropriately destroy the product at the facility and submit documentation to Lilly Cares confirming that the product has been appropriately
destroyed. If I do not return or destroy the product provided and not used for the applicable enrolled patient, I will be billed for the product and I
agree to 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.
Prescriber Signature: Date:
(SIGNATURE REQUIRED)
Name of Prescriber:
Please print name
Name of Lilly Cares Applicant: DOB:
Please print name
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FOUNDATION Patient Assistance Program Oncology Application LILLY CARES

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Completed 16 June 2022

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