This is your Strattera Savings Card To the pharmacist

FIRST MONTH FREE. Then pay as little as $25 Only valid for commercially insured patients
per month for the next 11 refills, with a maximum Submit claim to patient's primary insurance first
savings of $75 per month.*
If patient qualifies per the terms of the offer, submit this offer as a secondary
* This offer is invalid for patients whose prescription claim for the co-pay using the Coordination of Benefits field with coverage code
claims are eligible to be reimbursed, in whole or in type 08
part, by any governmental program. See below for full
- For first card use, this card will cover full amount of patient's co-pay
eligibility criteria.
- For subsequent uses, this card will cover the patient's co-pay balance up to
a maximum of $75
How to use this Savings Card Please charge the patient any remaining balance due
By accepting this offer, you certify that you understand and agree to comply
with the offer terms set forth herein
YOUR SAVINGS CARD If you are required to do so under the terms of your third-party payer contracts
IS ACTIVATED or as otherwise required by law, you should notify the affected third-party payer
of your redemption of this coupon
Transmit claim online to RxBin# 015251
This card must be accompanied by a prescription and can only be used by one
Show your Savings Card and
patient
prescription to your pharmacist.
Print this page, or you may be able For assistance in filing this claim, call the pharmacy Help Desk at
to show it on your mobile device. 1-800-510-4836

If you have any questions about the STRATTERA Savings Card Program, please
call 1-866-923-1953.

FOR PHARMACY USE This offer may be terminated, rescinded, revoked, or amended by Lilly USA,
LLC, at any time without notice.

RxBIN#: 015251 By using the STRATTERA Savings Card, you attest that you meet the eligibility
criteria and will comply with the Terms and Conditions described below:
PCN#: PRX2000
* Eligibility criteria: Offer void where prohibited by law. This offer is invalid for
GROUP#: STRACPWEB patients without commercial insurance coverage or those whose
prescription claims for STRATTERA are eligible to be reimbursed, in whole
IDENTIFICATION#: SCPW9315570 or in part, by any governmental program, including, without limitation,
Medicaid, Medicare, Medicare Part D, Medigap, DOD, VA,
EXPIRES: 5/26/2017 TRICARE/CHAMPUS, or any State Patient or Pharmaceutical Assistance
Program. If you live in Massachusetts, the Card expires on the earlier of: (i) the
expiration date of this Card (5/26/17) or (ii) the date an AB rated generic
equivalent for STRATTERA becomes available. Available only in the US and
If you are using a mail order pharmacy Puerto Rico for residents of the US and Puerto Rico. By accepting this offer, you
agree that if you are required to do so under the terms of your insurance
The Savings Card is also available to patients using coverage for this prescription or are otherwise required to do so by law, you
a mail order pharmacy. Mail in a copy of your should notify your insurance carrier of your redemption of this Card. This offer is
activated Savings Card along with your receipt not valid with any other program, discount, incentive, or similar offer involving
showing the name of the drug, date filled, and STRATTERA. It is prohibited for any person to sell, purchase, or trade; or to offer
amount paid and your name and address to: to sell, purchase or trade, or to counterfeit this Card. This offer may be terminated,
rescinded, revoked or amended by Lilly USA, LLC at any time without notice. This
STRATTERA Savings Card Program Card is not health insurance. This Card expires on 5/26/2017.
PO Box 42638
Cincinnati, OH 45242 No use of the card or benefit previously derived from the card will be honored after
May 26, 2017. Use of this card does not create any obligation or involve any past
or future purchase requirement. If you have any questions about the STRATTERA
Please see full Prescribing Information and Savings Card Program, please call 1-866-923-1953.
Medication Guide, including Boxed Warning.

PP-AT-US-0261 12/2015 Lilly USA, LLC 2015. All rights reserved.

Strattera is a trademark owned or licensed by Eli Lilly and
Company, its subsidiaries or affiliates. You understand and agree to
comply with these offer terms.