RXBIN# IDENTIFICATION# PERSON CODE# EXPIRES
610575 KP017760357 001 12/31/08
This voucher is valid for reimbursement at retail pharmacies only.
  • Please dispense this Eli Lilly and Company product at no charge to the patient. Transmit claims online to Wellpoint NextRx.
  • This voucher should be accompanied by a prescription and is for new prescriptions only.
  • Processor requires Valid Prescriber DEA #, Patient Name, and Person Code for claim adjudication.
  • Please remove this sample identification number from the patient profile after the claim is processed.
  • For assistance in filing this claim, please call the Help Desk at 1-866-291-1621.
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 HUMALOG KWIKPEN, HUMALOG MIX75/25 KWIKPEN OR HUMALOG MIX50/50 KWIKPEN IS 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. PATIENT ACCEPTANCE OF THIS OFFER MUST BE CONSISTENT WITH PATIENTS THIRD-PARTY PAYER CONTRACTS, IF ANY; AND PATIENTS 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. THIS OFFER EXPIRES DECEMBER 31, 2008. VOUCHER NOT VALID WITH ANY OTHER PROGRAM, DISCOUNT OR INCENTIVE INVOLVING HUMALOG KWIKPEN, HUMALOG MIX75/25 KWIKPEN OR HUMALOG MIX50/50 KWIKPEN. 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 (E.G., MEDICAID, MEDICARE, PRIVATE INSURANCE, OR OTHER HEALTHCARE PROGRAMS) FOR REIMBURSEMENT. THIS OFFER MAY BE TERMINATED BY ELI LILLY AND COMPANY AT ANY TIME.
HI50850 PRINTED IN USA. COPYRIGHT © 2008, ELI LILLY AND COMPANY. ALL RIGHTS RESERVED.