PP-AP-US-0604 Lilly Cares Application January 2024.indd

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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

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

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 2024 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) $45,180 $61,320 $77,460 $93,600

Group 2 Medications (at or below 400% FPL) $60,240 $81,760 $103,280 $124,800

Group 3 & Group 4 Medications (at or below 500% FPL) $75,300 $102,200 $129,100 $156,000

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nancial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dened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.

Group 1 Medications

• Cialis

(tadalafil) tablets

• Cymbalta

(duloxetine delayed-

release capsules)

• Evista

(raloxifene hydrochloride)

tablet

• Forteo

(teriparatideinjection)

• Prozac

(fluoxetinecapsules)

Group 2 Medications

• Basaglar

(insulinglargineinjection)

• Emgality

(galcanezumab-gnlm)

injection

• Humalog

(insulinlisproinjection)

• Humulin

(human insulin)

• Lyumjev

(insulin lispro-aabc) injection

• Reyvow

(lasmiditan)

• Trulicity

(dulaglutide)injection

Group 3 Medications

• Humatrope

(somatropin) for

injection

• Omvoh

™

(mirikizumab-mrkz)

infusion

†

• Omvoh

™

(mirikizumab-mrkz)

injection

• Olumiant

(baricitinib) tablets

• Taltz

(ixekizumab)injection

Group 4 Medications

• Alimta

(pemetrexedforinjection)

†

• Cyramza

(ramucirumab)injection

†

• Erbitux

(cetuximab)injection

†

• Jaypirca

(pirtobrutinib) tablets

• Kisunla

™

(donanemab-azbt) injection

†

• Retevmo

(selpercatinib) capsules

• Verzenio

(abemaciclib) tablets

†

indicates infused medication

Lilly Cares is temporarily not accepting new applications for Trulicity

. Lilly Cares will accept applications for

re-enrollment of those currently enrolled for Trulicity

. Visit lillycares.com for updates.

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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

How do I apply to the Lilly Cares Program?

To apply, you must complete the following steps:

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

Read the Privacy Notice (page 3)

Complete the Patient Information Section (pages 4 and 5)

Read and sign the Patient Certification Agreement (page 6)

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

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.

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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

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 interac

t with our services and the information you choose to

provide. We may collect:

• Health conditions, treatments, diseases, or diagnosis

• Social, psychological, behavioral, and medical interventions

• Health-related surgeries or procedures

• Use or purchase of prescribed medication

• Bodily functions, vital signs, symptoms, or measurements of

other types of consumer health data

• Diagnoses or diagnostic testing, treatment, or medication

• Reproductive or sexual health information

• Biometric data

• Geneticdata

• Data that identifies a consumer seeking health care services

• Prescription and medical health insurance benefits

information

• 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.

• Analytics and improvement.

• Customization and personalization.

• Marketing and advertising.

• Security and protection of rights.

• Legal proceedings and obligations.

• Generalbusinessandoperationalsupport.

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

datarights@lilly.com 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

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 privacy@lilly.com, 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).

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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

Patient Insurance Information

Patient Information Section

Please ll out all elds on this page. If your application isn’t complete,

it might delay your enrollment in the Lilly Cares Program.

Last Name

ZIP Code

Middle Initial

State

Phone Number (optional)

First Name

City

Number of people in your household

Date of Birth (MM/DD/YYYY)

Annual Household Income before taxes

Address

Patient Income Information

Including you and

all family members.

Include wages, Social Security payments, disability and/or unemployment

benets,pensions,andanyotherincomeofyourselfandthoseinyourhousehold.

By providing your phone number and signing this form, you agree to receive automated phone and text messages

.Thesenotications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.

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).

Consultwithyourhealthcareprovidertoconrmdeliverylocation.Infusedmedicationsarenoteligibleforhomedelivery.

Where would you like your medication delivered?

To my home

To my healthcare provider’s office

When processing your application, you may be contacted by Lilly Cares to provide documentation showing your income.

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 ofce, specialty pharmacy, or a

family member.

No Yes

What type of health insurance do you have? (Check all that apply)

When processing your application, a benets verication will be conducted. Insurance documentation may be requested.

 I do not have health insurance

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.

For example, Medigap, Medicare Advantage, employer private insurance.

For example, employer-sponsored plan and health insurance marketplace plan.

 Medicare Part D

 Medicare Part B without supplemental/secondary insurance

 Medicare Part B with supplemental/secondary insurance

 Medicare Advantage Plan

 Medicaid

 VA or Military

 Private Insurance (excluding Medicare Part D)

Other Insurance TypeMedicare

For Group 4 Medications, has your insurance denied coverage for the prescribed product?

Yes - If yes, please include documentation. For details, visit: https://www.lillycares.com/assets/pdf/insuranceverification.pdf

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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

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.

Patient Authorization for Automatic Prescription Rells (“Auto-rell”)

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rellmymedication.IwillcallLillyCareswhenIamdueforarell.

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)

Family Member/Caregiver Other, please specify

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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

Patient Certication Agreement

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 an 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.

Date (MM/DD/YYYY)

SIGNATURE OF PATIENT OR LEGAL GUARDIAN (REQUIRED)

Name of Patient (Please print)

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

Page 7 of 9

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

Health Insurance Portability and Accountability Act

(HIPAA) Authorization

I consent to the sharing, use, and receipt of information about me, as described:

IunderstandthatIormyhealthcareprovider’sofce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afliates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, and prescription and medical health

insurance information.

• 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.

• 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.

• 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.

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

• 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.

End of Patient Section

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

Name of Patient (Please print)

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

Page 8 of 9

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

Please indicate the method for submitting a prescription to Lilly Cares. Please read carefully and submit prescription via one method only.

Electronic prescription: select Fortrea 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.

Infused ONCOLOGY Product Replacement Request

A prescription is not required for product replacement

Alimta Cyramza Erbitux

Infused ONCOLOGY ICD 10 Code

Required for Alimta

, Cyramza

, & Erbitux

ONLY:

(Infused oncology medications must be used only for an FDA approved

indication or compendia-supported use.)

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,qualied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rells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benetfromanyProgramrepresentativesforprescribinganEliLillyandCompanydrug.

• Programrepresentativesarenotresponsibleforling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benet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.

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

Patient Name (Please print) Medication(s) RequestedDate of Birth (MM/DD/YYYY)

Ofce Contact Name Ofce Contact Phone Ofce Contact Fax Date (MM/DD/YYYY)

Prescriber Name (

Please print)

Administration Date Dosage # of Vials Vial Size

PRESCRIBER SIGNATURE (REQUIRED)

Healthcare Provider/Prescriber Section

Conrmations and Agreements

Healthcare Provider

(doctor or nurse) to ll

this section out.

DO NOT complete page 9 of the application if submitting an electronic prescription or faxing a provider-generated prescription.

Page 9 of 9

4 Month (max) 3 Month 2 Month 1 Month

Vial (not available for Basaglar

, Humalog

U-200, Humalog

50/50,orLyumjev™U-200)

KwikPen

(not available for Humulin

R 100 units/mL)

Cartridge (only available for Humalog

100 units/mL)

Lilly Cares Prescription Template

Patient Information

Note: If the patient’s application is approved, medication will be delivered to the location selected by the patient. Please

coordinate with your patient to ensure appropriate delivery location. Infused medications are not eligible for home delivery.

Please ll out all elds. An incomplete form may delay the patient’s enrollment in the Lilly Cares Program.

Patient Name

Healthcare Provider Name and Title (Please print)

State License # and State

Ofce Contact Name

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

Address

NPI #

Ofce Contact Phone

DEA # (as required)

Healthcare Provider Information

If yes, select the prescribed insulin:

Address City

Other Medications

State

City

ZIP Code

State ZIP Code Phone Number Fax Number

Date of Birth (MM/DD/YYYY)

Today's Date (MM/DD/YYYY)

Drug AllergiesPhone Number

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 Fortrea Specialty Pharmacy (NPI 1780811125) in your eRx software.

Medication Strength Maximum Dose per Day

Directions (Please print)

Healthcare Provider:

DO NOT complete if submitting

an electronic prescription or

faxing a provider generated

prescription

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

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

Select one:

Dispense as written Substitution Brand Exchange Permitted

Rell #

Yourstatemayrequirethatprescriptionsfollowcertaincontentrequirementsoruseaparticularform.Non-compliancewithstate-specic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.

Lilly Cares is temporarily not accepting new applications for Trulicity

. Lilly Cares will accept applications for

re-enrollment of those currently enrolled for Trulicity

. Visit lillycares.com for updates.

Are you prescribing insulin?

Yes No

PRESCRIBER SIGNATURE