ERBITUX^® (cetuximab)

By enrolling in the Lilly Oncology Infused Products Savings Card Program (“Program”) and using the Lilly Oncology Infused Products Savings Card (“Card”), you attest that you meet the eligibility criteria, agree to, and will comply with the terms and conditions described below:

Eligibility:

Card Terms and Conditions
You must (a) have commercial drug insurance that covers your prescribed Covered Medicine, but your insurance does not cover the full cost and (b) have a prescription for an approved use consistent with FDA-approved product labeling to pay as little as $25 for each infusion of your prescribed Covered Medicine. The Program will cover your co-pay or coinsurance for your prescribed Covered Medicine less $25, up to a maximum monthly savings of up to wholesale acquisition cost plus usual and customary fees and a separate maximum annual savings of up to $25,000 per calendar year. Card may be used for a maximum of up to 12 infusions per calendar year. After the monthly and/or annual maximum savings are reached, you will be responsible for paying any remaining monthly/annual out-of-pocket costs. Program may provide support for infusions with a date of service that falls within 120 days prior to the date the enrollment form is received by the Program.

To receive Program savings, your healthcare provider must submit a claim for coverage to your medical insurance provider. If your medical insurance provider does not cover the full cost of the claim, your healthcare provider must then submit an Explanation of Benefits (EOB) form and a CMS 1450 or 1500 form to www.LillyOncologyPortal.com within 180 days of the infusion date of your prescribed Covered Medicine. The submitted form must include the name of the insurer and plan and demonstrate that a Covered Medication was the medication administered. You understand and agree that Lilly will make a payment of your Program savings on your behalf to your healthcare provider. 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 12/31/2025.

Additional Terms and Conditions
If you have an insurance plan that is participating in an alternate funding program (“AFP”) that requires you to apply to the Lilly Oncology Infused Products 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 your prescribed Covered Medicine, you are not eligible for and are prohibited from using the Lilly Oncology Infused Products 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 the Lilly Oncology Infused Products Savings Card Program. You agree to inform the Lilly Oncology Infused Products Savings Card Program if you are or become a member of such an alternate funding program.
You are responsible for any applicable taxes, fees, and any amount that exceeds the monthly or annual maximum savings. Monthly and annual maximums 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 your prescribed Covered Medicine, only allows partial coverage for your prescribed Covered Medicine, removes coverage for your prescribed Covered Medicine and requires you to utilize the Card, does not provide a material level of financial assistance for the cost of your prescribed Covered Medicine, or does not apply Card payments to satisfy your co-payment, deductible, or coinsurance for your prescribed Covered Medicine.

Program savings are limited to the co-pay or coinsurance costs for your prescribed Covered Medicine only, subject to a monthly and annual maximum savings, outlined above. The Program will not cover, and shall not be applied toward, the cost of any dosing procedure, any other healthcare provider service or supply charges or other treatment costs, or any costs associated with a hospital stay. Participation in the Program requires a valid patient HIPAA authorization to enroll in the Program. 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. If at any time you begin receiving coverage under any state, federal, or government funded healthcare program, you understand that you will no longer be eligible for the Lilly Oncology Infused Products Savings Card Program and agree to call the Lilly Support Services for Oncology at 1-800-545-5979 to stop participation. You may not 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 your prescribed Covered Medicine. 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. THIS 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. Lilly’s sole discretion to terminate, rescind, revoke, or amend Card eligibility criteria and/or Card terms and conditions includes the right to terminate any individual Card if Lilly determines, in its sole discretion, that a patient does not satisfy the Card’s eligibility criteria or is using or has attempted to use the Card inconsistently with these Terms and Conditions. Eligibility criteria, and terms and conditions for the Lilly Oncology Infused Products Savings Card Program may change from time to time; the most current version can be found at https://www.oncologysupport.lilly.com . 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 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 12/31/2025.

TRICARE^® is a registered trademark of the Department of Defense (DoD), DHA.