LillyDirect Self Pay Pharmacy Purchase Offer Terms

• I have been prescribed Emgality for an approved use consistent with the FDA-approved product labeling.
• I will not seek payment or accept reimbursement, either directly or indirectly, from any insurance plan or other third-party payer, including any state or federal health care program or any private or other insurance plan, for Emgality purchased under the Program, regardless of whether the payer covers Emgality.
• I will not count the amount I pay for Emgality purchased under the Program towards my insurance deductible or out-of-pocket spending requirements.
• If I am enrolled in Medicare Part D, I will not count any portion of the amount I pay for Emgality under the Program, or any costs associated with my purchase of Emgality under the Program, towards my Medicare Part D true out-of-pocket ("TrOOP") costs.
• I am purchasing Emgality for my own use. I will not sell, repackage, reformulate, trade, barter, export, or distribute for sale Emgality purchased through the Program.
• A monthly supply of Emgality is defined as one 120 mg prefilled pen per month.
• I am a resident of the United States or Puerto Rico.
• I am 18 years of age or older.