RXBIN# IDENTIFICATION# PERSON CODE# EXPIRES
610575 KP016761920 001 04/09/2010
Valid for: Humalog KwikPen, Humalog KwikPen 75/25, Or Humalog KwikPen 50/50
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 Wellpoint NextRx. Processor requires Valid Prescriber ID#, Patient Name, and Person Code for claim adjudication. For assistance call 1-866-291-1621. Limit: (1) 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THIS OFFER MAY BE TERMINATED, RESCINDED, REVOKED, OR AMENDED BY LILLY USA, LLC AT ANY TIME.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 VOUCHER SHALL NOT BE SUBMITTED TO ANY THIRD PARTY PAYER, PUBLIC OR PRIVATE, (EG, MEDICAID, MEDICARE, PRIVATE INSURANCE, ANY GOVERNMENTAL PROGRAM, ANY OTHER FEDERAL OR STATE PROGRAM SUCH AS CHAMPUS, THE VA, TRICARE, OR A STATE PHARMACEUTICAL ASSISTANCE PROGRAM) FOR REIMBURSEMENT. OFFER VALID IN THE US ONLY. THIS OFFER IS NOT VALID WITH ANY OTHER PROGRAM, DISCOUNT, OR INCENTIVE INVOLVING HUMALOG KWIKPEN, HUMALOG KWIKPEN 75/25, OR HUMALOG KWIKPEN 50/50. IT IS ILLEGAL FOR ANY PERSON TO SELL, PURCHASE, OR TRADE; OR TO OFFER TO SELL, PURCHASE, OR TRADE; OR TO COUNTERFEIT THIS COUPON. NO PURCHASE REQUIRED. PRINTED IN USA © 2009, LILLY USA, LLC. HUMALOG KWIKPEN, HUMALOG KWIKPEN 75/25, AND HUMALOG KWIKPEN 50/50 ARE TRADEMARKS OF ELI LILLY AND COMPANY. YOU UNDERSTAND AND AGREE TO COMPLY WITH THESE OFFER TERMS.
HI50850 PRINTED IN USA. COPYRIGHT © 2009, LILLY USA, LLC. ALL RIGHTS RESERVED.