Coupon

Dear Patient,

This pharmacy voucher is being provided by Eli Lilly and Company for one free HumaPen^® LUXURA™ HD. This voucher should be taken, along with a prescription for the pen, to your local pharmacy where you will receive this product without charge. HumaPen LUXURA HD is intended for use with Humalog^® (insulin lispro injection [rDNA origin]) 3 mL cartridges, which are available by prescription only and are sold separately. Needles may also require a prescription and are sold separately. By using this voucher you are agreeing to the terms and conditions contained herein (see below).

For product information, call 1-800-LillyRx (1-800-545-5979).
Hours of operation: Monday-Friday, 9AM-5PM Eastern Time.

Redeemable for HumaPen LUXURA HD

	RxBIN#	PCN#	GROUP#	IDENTIFICATION#	EXPIRES#
	610494	3333	HMPNWB	HUWP8249626	03/28/2012

To the Pharmacist:

This voucher is valid for reimbursement at retail pharmacies only, subject to the terms and conditions set forth herein.
Please dispense this Eli Lilly and Company product without charge to the patient.
Transmit the claim online to RxSolutions.
This voucher is for new prescriptions only, and must be accompanied with a valid prescription.
Limit 1 voucher per patient. No Refills. Offer good only in the United States.
Please remove this sample identification number from the patient profile after the claim is processed.
Offer cannot be combined with any other free trial, coupon, rebate, or similar offer.
For assistance filing this claim, please call the Pharmacy Help Desk at 1-800-510-4836.
Processor requires Valid Prescriber ID#, Patient Name, and DOB for claim adjudication.

OFFER TERMS: OFFER VOID WHERE PROHIBITED BY LAW. PRODUCT DISPENSED PURSUANT TO THE TERMS OF THIS OFFER SHALL NOT BE SUBMITTED TO ANY THIRD-PARTY PAYER, PUBLIC OR PRIVATE, (EG, MEDICAID; MEDICARE; PRIVATE INSURANCE; ANY GOVERNMENTAL PROGRAM; OR ANY OTHER FEDERAL OR STATE PROGRAM, SUCH AS CHAMPUS, THE VA, TRICARE, OR A STATE PHARMACEUTICAL ASSISTANCE PROGRAM) FOR REIMBURSEMENT. OFFER VALID ONLY IN THE US. THIS OFFER IS NOT VALID WITH ANY OTHER PROGRAM, DISCOUNT, OR INCENTIVE INVOLVING ANY LILLY INSULIN BRAND. IT IS ILLEGAL FOR ANY PERSON TO SELL, PURCHASE, OR TRADE OR OFFER TO SELL, PURCHASE OR TRADE, OR TO COUNTERFEIT THIS OFFER. NO PURCHASE REQUIRED. USE OF THIS OFFER DOES NOT CREATE ANY OBLIGATION OR INVOLVE ANY PAST OR FUTURE PURCHASE REQUIREMENT. THIS OFFER MAY BE TERMINATED, RESCINDED, REVOKED, OR AMENDED BY LILLY USA, LLC AT ANY TIME, WITHOUT NOTICE. YOU UNDERSTAND AND AGREE TO COMPLY WITH THESE OFFER TERMS. HUMALOG^® AND HUMAPEN^® LUXURA™ ARE REGISTERED TRADEMARKS OF ELI LILLY AND COMPANY. HUMALOG^® AND HUMAPEN^® LUXURA™ HD ARE AVAILABLE BY PRESCRIPTION ONLY. LILLY SCRIPT™ IS A TRADEMARK OF ELI LILLY AND COMPANY.