Dear Patient,

This 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, USP [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-8PM Eastern Time.

Redeemable for HumaPen LUXURA HD

Valid For: HumaPen LUXURA HD

Patient: Redeem at local retail pharmacy.

Pharmacist: By accepting this offer you certify that you understand and agree to comply with the offer terms set forth herein. Submit claim to RxBin# 015251. Processor requires Valid Prescriber ID#, Patient Name, and DOB for claim adjudication. For assistance call 1-800-510-4836.

Limit: One (1) HumaPen LUXURA HD voucher per patient per 12 month period.

THIS OFFER MAY BE TERMINATED, RESCINDED, REVOKED, OR AMENDED BY LILLY USA, LLC AT ANY TIME.


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OFFER DOES NOT CREATE ANY OBLIGATION OR INVOLVE ANY PAST OR FUTURE PURCHASE REQUIREMENT.THIS OFFER MAY BE TERMINATED, RESCINDED, REVOKED, OR AMENDED BY LILLY USA, LLC AT ANY TIME, WITHOUT NOTICE.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.