*Terms and conditions:
Subject to Lilly USA, LLC’s (Lilly’s) right to terminate, rescind, revoke or amend the Taltz Savings Card Program
(“Program”) and the Taltz Savings Card (“Card”) eligibility criteria and/or Card terms and conditions which may occur at
Lilly’s sole discretion, without notice, and for any reason, the Card expires and savings end on 12/31/2026 or 24 months
after you first use the Card, whichever comes first. Card savings are not available to patients without commercial drug
insurance or who are enrolled in any state, federal, or government funded healthcare program, including, without
limitation, Medicaid, Medicare, Medicare Part D, Medicare Advantage, Medigap, DoD, VA, TRICARE®/CHAMPUS, or
any state prescription drug assistance program.
MONTHLY AND ANNUAL MAXIMUM SAVINGS: For patients with commercial drug insurance coverage for Taltz: You
must have commercial drug insurance that covers Taltz® (ixekizumab) and a prescription consistent with FDA-approved
product labeling to pay as little as $5 for a 1-month prescription fill of Taltz. Month is defined as 28-days and up to 3
pens. Card savings are subject to a maximum monthly savings of wholesale acquisition cost plus usual and customary
pharmacy charges and a separate maximum annual savings of up to $9,450 per calendar year. Card may be used for up to
14 prescription fills per year and up to a maximum of 24 prescription fills over the lifetime of the Program, subject to the
maximum monthly and annual savings limit. Participation in the Program requires a valid patient HIPAA authorization
upon enrollment into the Program. Subject to Lilly USA, LLC’s right to terminate, rescind, revoke, or amend Card
eligibility criteria and/or Card terms and conditions which may occur at Lilly’s sole discretion, without notice, and for any
reason, Card expires and savings end on 12/31/2026 or 24 months after you first use the Card, whichever comes first.
For patients with commercial drug insurance who do not have coverage for Taltz: You must have commercial drug
insurance that does not cover Taltz and a prescription consistent with FDA-approved product labeling to pay as little as
$25 for 1-month supply of Taltz. Month is defined as 28-days and up to 3 pens. Card savings are subject to a maximum
monthly savings and a separate maximum annual savings. Card may be used for up to 14 prescription fills per year and
up to a maximum of 24 prescription fills over the lifetime of the Program, subject to the maximum monthly and annual
savings limit. Participation in the Program requires submission of a prior authorization (PA) prior to the first prescription
fill. If coverage is denied, an appeal must be submitted prior to 5th month prescription fill. To remain eligible for the
Program, a new PA, appeal, or medical exception must be submitted prior to the 13th prescription fill and as required by Lilly at its
sole discretion. Participation in the Program requires a valid patient HIPAA authorization to remain in the Program.
Subject to Lilly USA, LLC’s right to terminate, rescind, revoke, or amend Card eligibility criteria and/or Card terms and conditions, which may occur at Lilly’s sole discretion, without notice, and for any reason, Card expires and savings end on
12/31/2026 or 24 months after you first use the Card, whichever comes first.
ADDITIONAL TERMS AND CONDITIONS:
You are responsible for any applicable taxes, fees, and any amount that exceeds the monthly or annual maximum benefits. Card activation is required. This Card may be terminated, rescinded, revoked, or amended by Lilly at any time without notice and for any
reason. Subject to additional
terms and conditions. Eligibility criteria and terms and conditions for the Taltz Savings Card Program may change from time to time at Lilly’s sole discretion and for any reason; the most current version can be found at
https://Taltz.com. Card benefits void where prohibited by law.
TRICARE® is a registered trademark of the Department of Defense (DoD), DHA.