Savings Card

ID: YDXD1718941 Card expires at the end of

GROUP: FCLDSAF8 each calendar year

Your savings card is BIN: 018844

PCN: 3F
THIS OFFER IS INVALID FOR
PATIENTS WHOSE PRESCRIPTION
CLAIMS ARE ELIGIBLE TO BE

activated and ready to use.

REIMBURSED, IN WHOLE OR IN PART,
BY ANY GOVERNMENTAL PROGRAM.
SEE BELOW FOR ADDITIONAL

Go to the pharmacy today.

DETAILS/RESTRICTIONS.

Thank you for raising your hand.

We’re pleased we could help you. Provide this savings card at the pharmacy.
Please call if you have any questions or concerns.

Questions? Call 1-833-808-1234

Terms and Conditions Available only in the US and Puerto Rico for residents of the US and Puerto Rico
who are 18 years of age or older. By accepting this offer, you agree that if you are
Covered Insulins: required to do so under the terms of your insurance coverage for this prescription
or are otherwise required to do so by law, you should notify your Insurance
“Covered Insulins” consist of the following products: Humalog® (insulin lispro
Carrier of your redemption of this Card. This offer cannot be combined or utilized
injection 100 units/mL) U-100 vial (10 mL), Humalog U-100 KwikPen ,
® ®
with any other program, discount, discount card, cash discount card, coupon,
Humalog® U-100 cartridge (3 mL), Humulin® R U-500 (insulin human) injection
incentive, or similar offer involving Covered Insulin. It is prohibited for any person
KwikPen® (500 units/mL), Humulin R U-500 vial, Insulin Lispro Injection
to sell, purchase or trade; or to offer to sell, purchase or trade, or to counterfeit
(100 units/ mL) U-100 vial (10 mL), Insulin Lispro Injection U-100 KwikPen , ®
this Card. This offer may be terminated, rescinded, revoked or amended by Lilly
Humalog U-200 KwikPen , Humalog Junior KwikPen , Insulin Lispro Injection
® ® ® ®
USA, LLC at any time without notice. Card activation required. This Card is not
Junior KwikPen®, Humalog® Mix50/50™ (insulin lispro protamine and insulin
health insurance. Card expires at the end of each calendar year.
lispro injectable suspension) 100 units/mL vial (10 mL), Humalog Mix50/50™
®

KwikPen , Humalog Mix75/25™ (insulin lispro protamine and insulin lispro

To the Pharmacist:
® ®

injectable suspension) 100 units/mL vial (10 mL), Humalog® Mix75/25™

KwikPen®, Insulin Lispro Protamine and Insulin Lispro Injectable Suspension
Mix75/25™ KwikPen®, Humulin® N vial (10 mL), Humulin® N KwikPen®,
Humulin® R U-100 vial (10 mL), Humulin® 70/30 vial (10 mL), Humulin® 70/30
KwikPen®, BASAGLAR® (insulin glargine) injection KwikPen® (100 units/
mL), Lyumjev® (insulin lispro-aabc) KwikPen® (100 units/mL), Lyumjev® (insulin
lispro-aabc) U-200 KwikPen® (200 units/mL), and Lyumjev® (insulin lispro-
aabc) U-100 vial (10 mL), Lyumjev® Tempo Pen®, BASAGLAR ® Tempo Pen®,
Humalog Tempo Pen , and REZVOGLAR™ (insulin glargine-aglr) injection
® ®
KwikPen (100 units/mL).
By using the Savings Card (“Card”), you attest that you meet the eligibility criteria,
agree to, and will comply with the terms and conditions described below:
Offer good for up to 12 calendar months. Patients must have commercial drug
insurance to pay as little as $35 per prescription per month for a 30-day supply of
your Covered Insulin. Offer subject to a monthly cap of wholesale acquisition cost
plus usual and customary pharmacy charges and a separate annual cap of
$16,000. Offer void where prohibited by law. Patient is responsible for any
applicable taxes, fees, or amounts exceeding monthly or annual caps. This offer
is invalid for patients without commercial drug insurance or whose prescription
claims for Covered Insulin are eligible to be reimbursed, in whole or in
part, by any governmental program, including, without limitation, Medicaid,
Medicare, Medicare Part D, Medigap, DoD, VA, TRICARE®/CHAMPUS, or any
State Patient or Pharmaceutical Assistance Program. This offer is not valid for:
Massachusetts residents if an AB-rated generic equivalent is available; California
residents if an FDA-approved therapeutic equivalent is available. This offer is void
for California residents and cannot be redeemed in the State of California for the
following products: Humulin® N vial (10 mL), Humulin® N KwikPen®, Humulin® R
U-100 vial (10 mL), Humulin® 70/30 vial (10 mL), Humulin® 70/30 KwikPen®.
• This Card must be accompanied by a valid prescription for one of the
above-mentioned Covered Insulins and can only be used by one Patient.
By accepting this offer, you certify that you understand and agree to
comply with the offer terms set forth herein.
• If you are required to do so under the terms of your third-party payer
contracts or as otherwise required by law, you should notify the affected
third-party payer of your redemption of this offer.
• Offer is not valid for patients who are eligible to have their prescriptions
reimbursed in whole or part by any governmental program.
• Please return Card to Patient after claim is processed.
• Transmit claim online to RxBIN 018844. Processor requires valid
Prescriber ID #, PCN, Patient Name, and DOB for claim adjudication.
• Card may be used for up to 12 calendar months of one of the above-
mentioned Covered Insulins.
• For Insured/Covered Patients – Submit the co-pay authorized by the
patient’s primary insurance as a secondary claim to Eversana using BIN
018844 and using the Coordination of Benefits fields with Coverage Code
type 08. This will reduce the eligible patient’s out-of-pocket costs to $35,
subject to monthly cap and separate annual cap of $16,000.
• Pharmacists with questions, please call the Pharmacy Benefit Manager
at 1-855-282-4888.

PP-LD-US-2740 03/2023 ©Lilly USA, LLC 2023. All rights reserved. Names of Lilly Covered Insulins are registered
trademarks or trademarks owned or licensed by Eli Lilly and Company, its subsidiaries or affiliates, and are available by
prescription only. TRICARE® is a registered trademark of the Department of Defense (DoD), DHA.