Dear Patient,
This pharmacy voucher is being provided by Eli Lilly and Company for one free HumaPen MEMOIR or one free HumaPen LUXURA HD. This voucher should be taken, along with a prescription for the Insulin Pen, to your local pharmacy where you will receive this product without charge. HumaPen MEMOIR and HumaPen Luxura HD are intended for use with Humalog® (insulin lispro injection [rDNA origin]) 3mL insulin cartridges, which are available by prescription only and should be purchased separately. Starting or changing insulin therapy should be done cautiously and only under medical supervision. Needles should also be purchased 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 MEMOIR or HumaPen LUXURA HD
RXBIN# IDENTIFICATION# PERSON CODE EXPIRES#
610575 HUPW9064429 001 04/09/2010
To the Pharmacist: This voucher is part of the Eli Lilly and Company LillyScript® Program.
  • 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 Wellpoint Next Rx.
  • 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 1-866-291-1621.
  • Processor requires "Patient Name", "Date of Birth" and "Valid Prescriber DEA/NPI#".
HI48609 PRINTED IN USA ©2007, ELI LILLY AND COMPANY. ALL RIGHTS RESERVED. THE BRAND NAMES INCLUDED ON THIS VOUCHER ARE PROPERTIES OF THEIR RESPECTIVE OWNERS. TERMS AND CONDITIONS: THIS OFFER INVALID FOR PATIENTS WHOSE PRESCRIPTION CLAIMS FOR HUMAPEN MEMOIR, HUMAPEN LUXURA HD AND HUMALOG CARTRIDGES ARE REIMBURSED BY (1) ANY GOVERNMENTAL PROGRAM, INCLUDING, WITHOUT LIMITATION, MEDICAID, MEDICARE, OR ANY OTHER FEDERAL OR STATE PROGRAM SUCH AS CHAMPUS, THE VA, OR A STATE PHARMACEUTICAL ASSISTANCE PROGRAM, OR (2) ANY THIRD-PARTY PAYER IN THE STATES OF MASSACHUSETTS OR RHODE ISLAND. PATIENT ACCEPTANCE OF THIS OFFER MUST BE CONSISTENT WITH PATIENT'S THIRD-PARTY PAYER CONTRACTS, IF ANY, AND PATIENT MUST AGREE TO MEET ANY REPORTING OBLIGATIONS. THIS OFFER IS ALSO INVALID WHERE PROHIBITED BY LAW, AND IS NOT AVAILABLE TO CLUBS AND GROUPS OR ORGANIZATIONS. COUPON NOT VALID WITH ANY OTHER PROGRAM, DISCOUNT, OR INCENTIVE INVOLVING HUMAPEN DEVICES. OFFER GOOD FOR U.S. RESIDENTS ONLY. VOID WHERE PROHIBITED BY LAW. PRODUCT DISPENSED PURSUANT TO TERMS OF THIS VOUCHER SHALL NOT BE SUBMITTED TO ANY THIRD-PARTY PAYOR, PUBLIC OR PRIVATE (EG, MEDICAID, MEDICARE, PRIVATE INSURANCE, OR OTHER HEALTHCARE PROGRAMS) FOR REIMBURSEMENT. THIS OFFER MAY BE TERMINATED BY ELI LILLY AND COMPANY AT ANY TIME.