Insulin Lispro Injection Shelf Stocking Adjustment Form

Please complete this form to be considered for a shelf stock adjustment related to on hand inventory of Insulin Lispro Injection as of the beginning of the day on January 1, 2022. On hand inventory that was purchased at a discount is not eligible for this adjustment. Inventory from multiple pharmacy locations may be grouped together for efficiency in this form, however only one check will be issued for eligible on hand inventory. Please ensure the address is on the form that you would like this adjustment to be mailed to. If multiple locations are grouped together, please email supporting documentation for each location separately to with a reference to the pharmacy name in the subject line. All forms must be submitted no later than March 31, 2022.

Go to for a FAQ with more information regarding the shelf stock adjustment for Insulin Lispro Injection as of January 01, 2022.

Pharmacy Information *

Example: 1234567890

Example: AB1234567

Product Inventory as of January 01, 2022

Product Description
Inventory Quantity *
NDC: 0002775205 Product Description: INSULIN LISPRO JR KWIKPEN® 100 UNITS/ML 3ML Inventory Quantity *:
Units: Boxes of 5 Pens
NDC: 0002773701 Product Description: INSULIN LISPRO 100 UNITS/ML 10ML Inventory Quantity *:
Units: Vials
NDC: 0002823305 Product Description: INSULIN LISPRO MIX75/25 KWIKPEN® 100 UNITS/ML 3ML Inventory Quantity *:
Units: Boxes of 5 Pens
NDC: 0002822259 Product Description: INSULIN LISPRO KWIKPEN® 100 UNITS/ML 3ML Inventory Quantity *:
Units: Boxes of 5 Pens

Wholesaler Information

Address for Check Reimbursement *

The entity or agent submitting this form (the “Submitter”), either on its own behalf or on behalf of its affiliated pharmacy or pharmacies (the “Affiliated Pharmacies”) represents and warrants that the accompanying inventory data submission is true and accurate in all material respects as it relates to inventory of Insulin Lispro Injection on hand as of the beginning of the day on January 1, 2022 (the “Inventory”) and that it has voluntarily agreed to participate in this shelf stock adjustment by Lilly USA LLC (“Lilly”).

Eligible Inventory must have been invoiced to Submitter or its Affiliated Pharmacies prior to January 1, 2022 but not dispensed to a patient until on or after January 1, 2022. On the date of submission, the Submitter represents and warrants that any Inventory submitted (a) was not purchased at a discount from any wholesaler (except for any discount from wholesaler subject to an agreement between Submitter or Affiliated Pharmacies and Lilly or an affiliate thereof) and (b) has not and will not be reimbursed or otherwise adjusted in price by any other party or through any other request. Submitter agrees, upon request, to provide Lilly with any and all supporting documentation that Lilly deems necessary to validate on hand inventory amounts as of the beginning of the day on January 1, 2022. Such documentation must be provided to Lilly no later than five (5) business days after such request is made. All requests for reimbursement must be made no later than March 31, 2022. Lilly reserves the right at its sole discretion to determine Submitter’s and/or its Affiliated Pharmacies’ eligibility for all or any part of the requested Insulin Lispro Injection shelf stock adjustment for the submitted Inventory, including (but not limited to) as the result of validation against wholesaler sales data. This shelf stock adjustment is intended as a good faith adjustment for bona fide Inventory, and not as an additional or duplicative discount or as an inducement or reward for the referral of any business reimbursable under any Federal health care program. In the event Lilly determines that all or any portion of a requested shelf stock adjustment was paid to Submitter in error, then Submitter will promptly remit to Lilly the amount of such overpayment upon demand from Lilly.

Submitter acknowledges and understands that this shelf stock adjustment for Insulin Lispro Injection relates exclusively to this product and pricing event and in no way implies or guarantees any other product or pricing event will be adjusted or handled through this method.