By enrolling in the Zepbound Savings Card Program (“Program”) and using the Zepbound Savings Card (“Card”),
you attest that you meet the eligibility criteria, and you agree to comply with the terms and conditions
described below:
Card Eligibility:
(1.) You have been prescribed Zepbound consistent with FDA approved product labeling
(2.) You are enrolled in a commercial drug insurance plan
(3.) You are not 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.
(4.) You are a resident of the United States or Puerto Rico
(5.) You are 18 years of age or older
Card Terms and Conditions
For patients with commercial drug insurance coverage for Zepbound: You must have commercial drug insurance
that covers Zepbound®(tirzepatide) and a prescription consistent with FDA-approved product
labeling to pay as little as $25 for a 1-month, 2-month, or 3-month prescription fill of Zepbound. Month is
defined as 28-days and up to 4 pens. Card savings are subject to a maximum monthly savings of up to $150 per
1-month prescription, $300 per 2-month prescription, or $450 per 3-month prescription fill and separate
maximum annual savings of up to $1,800 per calendar year. Card may be used for a maximum of up to 13
prescription fills per calendar year. Participation in the Program requires a valid patient HIPAA
authorization. Subject to Lilly USA, LLC’s (“Lilly”) 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 12/31/2024.
For patients with commercial drug insurance who do not have coverage for Zepbound: You must
have commercial drug insurance that does not cover Zepbound and a prescription consistent with FDA-approved
product labeling to obtain savings of up to $563 off your 1-month prescription fill of Zepbound. Month is
defined as 28-days and up to 4 pens. Card savings are subject to a maximum monthly savings of up to $563 and a
separate maximum annual savings of up to $7,319 per calendar year. Card may be used for a maximum of up to 13
prescription fills per calendar year. Participation in the Program requires a valid patient HIPAA
authorization. Subject to Lilly’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 12/31/2024.
Additional Terms and Conditions
If you have an insurance plan that is participating in an alternate funding program (“AFP”) (examples include,
but are not limited to, ImpaxRX, Payer Matrix, SHARx, Script Sourcing, and Paydhealth) that requires you to
apply to the Zepbound Savings Card Program or otherwise pursue specialty drug prescription coverage through an
alternate funding vendor as a condition of, requirement for, or prerequisite to coverage of Zepbound, you are
not eligible for and are prohibited from using the Zepbound Savings Card Program. AFPs include programs where
coverage, reimbursement, or patient out of pocket costs for a product in some way vary based on the
availability of a manufacturer co-pay program. AFPs may modify, delay, deny, restrict, or withhold insurance
benefits or coverage from patients, or exclude Lilly products from coverage contingent upon a member’s use of
Zepbound Savings Card Program. You agree to inform the Zepbound Savings Card Program if you are or become a
member of such an alternative funding program. You are responsible for any applicable taxes, fees, and any
amount that exceeds the monthly or annual maximum Card savings. Monthly and annual maximum savings are set at
Lilly’s sole and absolute discretion and may be changed with or without notice at any time for any reason. At
its sole discretion and with or without notice, Lilly may reduce, eliminate, or otherwise modify the Card
savings for any reason, including but not limited to if your commercial drug insurance plan imposes additional
requirements which limits or prevents you from receiving coverage for Zepbound, only allows partial coverage
for Zepbound, removes coverage for Zepbound and requires you to utilize the Card, does not provide a material
level of financial assistance for the cost of Zepbound, or does not apply Card payments to satisfy your
co-payment, deductible, or coinsurance for Zepbound. Card savings are not valid for: Massachusetts residents
if an AB-rated generic equivalent is available; California residents if an FDA-approved therapeutic equivalent
is available. You must meet the Card eligibility criteria, terms and conditions every time you use the Card.
Card activation is required. No party may seek reimbursement from your health insurance, any third party, or
any health savings, flexible spending, or other healthcare reimbursement accounts, for any amount of the
savings received through the Card. By utilizing the Card, you agree that if you are required to do so under
the terms of your insurance coverage for this prescription or are otherwise required to do so by law, you will
notify your Insurance Carrier of your redemption of the Card. Card savings cannot be combined or utilized with
any other program, discount, discount card, cash discount card, coupon, incentive, or similar offer involving
Zepbound. You agree that this Card savings is intended solely for the benefit of you, the patient, and that
the Card benefits are nontransferable. It is prohibited for any person to sell, purchase, or trade; or to
offer to sell, purchase, or trade, or to counterfeit the Card. The Card is not insurance. Lilly has the sole
right to interpret and apply Card eligibility criteria, and terms and conditions. Card eligibility, and terms
and conditions may be terminated, rescinded, revoked, or amended by Lilly at any time without notice and for
any reason. Eligibility criteria, and terms and conditions for the Zepbound Savings Card Program may change
from time to time; the most current version can be found at https://zepbound.lilly.com/coverage-savings. You may be required to
obtain a new Card, including if any Card terms and conditions have been terminated, rescinded, revoked, or
amended by Lilly. Card void where prohibited by law. Subject to Lilly’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, the Card expires and savings end on 12/31/2024.