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 reimbursement and co-pay assistance. Just specify the services your patient might need at the top of the application. If you need additional forms for 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

Filling out this form is the first step in determining if your patient qualifies for reimbursement and co-pay assistance.

 

New application as of October, 2017