• I have been prescribed Mounjaro 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 Mounjaro purchased under the Program, regardless of whether the payer covers Mounjaro.
• I will not count the amount I pay for Mounjaro 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 Mounjaro under the Program, or any costs associated with my purchase of Mounjaro under the Program, towards my Medicare Part D true out-of-pocket ("TrOOP") costs.
• I am purchasing Mounjaro for my own use. I will not sell, repackage, reformulate, trade, barter, export, or distribute for sale Mounjaro purchased through the Program.
• One fill is equal to a month's supply of Mounjaro which is defined as four pens per month.
• I am a resident of the United States or Puerto Rico.
• I am 18 years of age or older.

The Mounjaro logo, Mounjaro® and its delivery device base are registered trademarks owned or licensed of Eli Lilly and Company. Mounjaro is available by prescription only.

CMAT-26577 05/2026 ©Lilly USA, LLC 2026. All rights reserved.