- Patients must be aged 18 years or older
- Patients must be residents of the United States or Puerto Rico
- Patients must be treated with ALIMTA, CYRAMZA, ERBITUX, or Portrazza for an FDA-approved indication
- Patients must be commercially insured‡
- Patients enrolled in Medicaid, Medicare, Medigap, CHAMPUS, DOD, VA, TRICARE, or any state, patient, or pharmaceutical assistance program
- Patients enrolled in any other financial support program, discount, discount card, or incentive program involving ALIMTA, CYRAMZA, ERBITUX, or Portrazza
- Patients, pharmacists, and prescribers must not seek reimbursement from health insurance or any third party for any part of the benefit received by the patient through this program
†This offer is invalid for patients without commercial insurance coverage or those whose prescription claims are paid by Medicare Part D, Medicaid, Tricare or any other state or federal program. Offer void where prohibited by law and subject to change or discontinue without notice. Restrictions, including annual maximums, may apply. Card activation required. Subject to additional terms and conditions, which can be found here.
Patient Enrollment Steps
- Review program eligibility with your patient based upon the full criteria listed in the application
- Apply online or download an application to complete and fax with all required signatures to 1-877-366-0585
- Your patient’s application will be reviewed to determine eligibility
- The program may provide support for doses with a date of service that falls within 120 days before the date the application is received by the program
- After submitting the Lilly PatientOne Co-pay Program application, patients and providers will be informed of program enrollment status by Lilly PatientOne, indicating whether the patient meets eligibility requirements
- Approved patients will receive a welcome letter and the co-pay card in the mail from Lilly PatientOne
- Providers will be informed of patients’ enrollment status through a faxed letter with specific instructions on how claims can be filed
- The physician's office staff should remind patients to bring their co-pay card with them to their next appointment
Filing a claim for financial assistance
Please submit claims for financial assistance to Lilly PatientOne.
- Required information
- Member ID number from patient's Lilly PatientOne Co-pay Program card
- Primary health insurer Explanation of Payment/Remittance
- Fax submission: 1-877-366-0585
- Reimbursement claims MUST be submitted within 180 days of infusion to receive program benefits
- For additional direction regarding the filing of claims, please review the back of the Lilly PatientOne Co-pay Program card, or call 1-866-587-7321
* The following products are part of the co-pay program: ALIMTA (pemetrexed for injection), CYRAMZA (ramucirumab), ERBITUX (cetuximab), or Portrazza (necitumumab). Financial assistance is limited to the co-pay or coinsurance costs for doses of ALIMTA, CYRAMZA, ERBITUX, or Portrazza and does not cover any additional costs, including, but not limited to, fees related to the administration of ALIMTA, CYRAMZA, ERBITUX, or Portrazza.
† Additional patient terms and conditions will apply. See Lilly PatientOne Co-pay Terms and Conditions section for details.
‡ This offer is invalid for patients whose prescription claims for ALIMTA, CYRAMZA, ERBITUX, or Portrazza are eligible to be reimbursed, in whole or in part, by any governmental program, including, without limitation, Medicaid, Medicare, Medigap, CHAMPUS, DOD, VA, TRICARE, or any state patient, or pharmaceutical assistance program. Additional program restrictions apply. Please see full Terms and Conditions.