Forms

Lilly PatientOne Application

Update your billing and coding systems to include the permanent CYRAMZA® (ramucirumab) J-code: J9308, injection, ramucirumab, 5 mg. Issued by the Centers for Medicare & Medicaid Services (CMS), this permanent J-code is effective as of January 1, 2016.

Forms

Lilly PatientOne Application

Help your patients apply for Lilly PatientOne.

We realize insurance issues for oncology patients can be very complex. Getting your patients signed up for access services that may help shouldn’t be. That’s why Lilly PatientOne requires only one application for everything. Just specify the services your patient might need at the top of the application. If you need additional forms like dosage tracking or certification of brand drug usage, they’re right here, too.

If you have questions about enrolling your patients in Lilly PatientOne, please call us at 1-866-4PatOne (1-866-472-8663). Please fax the completed application to 1-877-366-0585.

Lilly PatientOne Application Denied Claims Appeals Resources

Lilly PatientOne application

This single form is the first step to determine if your patient qualifies for reimbursement services, co-pay or coinsurance assistance, or prescribed Lilly Oncology products at no cost. Lilly Oncology products are provided at no cost to qualifying patients through the Lilly Cares Foundation, Inc., an independent nonprofit organization. Lilly PatientOne collects information on behalf of Lilly Cares to assist Lilly Cares with its charitable mission. For more information about Lilly Cares, please visit LillyCares.com. This form also includes the physician’s acknowledgement of medical necessity and the patient’s written authorization for collection, use, and disclosure of his/her Protected Health Information (PHI).

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Lilly PatientOne Dosage Tracking form

Use this form to log administration of a prescribed Lilly Oncology product to help us determine the approved service date.

Certification of Brand Drug Usage form for GEMZAR® (gemcitabine for injection)

If you have prescribed GEMZAR for your patient and are requesting Lilly Oncology product replacement through the Lilly Cares Foundation, you will need to submit this certification with the program application or renewal form.