2017-18
|2019-2020 | | |Date |
|PBA Influenza Vaccine ORDER FORM | | | |
| | | | |
| | | | |
| | | | |
| | | |Contract Affiliation |
| | | | |
|Telephone |Fax |Purchase Order Number |
|FFF Account Number |State License Number |
|Order Placed By |Email Address |
|Customer's Special Instructions |
|Ship To |Bill To |
| | |
|Attn: |Attn: |
| | |
| | |
|Item No. |
|Trivalent |
|FLU001903 |Fluad™ Influenza Virus Vaccine |$40.782** | Box |$407.82** | |
| |0.5mL prefilled syringes, needleless, 10 per box | |of 10 | | |
| |65 years of age and older (no preservatives or latex) | | | | |
|Quadrivalent |
|FLU241910 |Afluria( Quadrivalent Influenza Virus Vaccine |$13.425** |Vial |$134.25** | |
| |5mL 10-dose vial | | | | |
| |6 months of age and older (no latex) | | | | |
|FLU031901 |Afluria( Quadrivalent Influenza Virus Vaccine |$14.346** | Box |$143.46** | |
| |0.5mL prefilled syringes, needleless, 10 per box | |of 10 | | |
| |3 years of age and older (no preservatives or latex) | | | | |
|FLU021920 |Afluria( Quadrivalent Influenza Virus Vaccine |$14.346** | Box |$143.46** | |
| |0.25mL prefilled syringes, needleless, 10 per box | |of 10 | | |
| |6-35 months of age (no preservatives or latex) | | | | |
|FLU141910 |Flucelvax( Quadrivalent Influenza Virus Vaccine |$15.459** |Vial |$154.59** | |
| |5mL 10-dose vial | | | | |
| |4 years of age and older (no antibiotics or latex) | | | | |
|FLU031903 |Flucelvax( Quadrivalent Influenza Virus Vaccine |$16.519** | Box |$165.19** | |
| |0.5mL prefilled syringes, needleless, 10 per box | |of 10 | | |
| |4 years of age and older (no preservatives, antibiotics or latex) | | | | |
|**Exclusive of Federal Excise Tax of $0.75 per dose |
| |
|Seqirus Returnability |
|Up to 25%, per presentation type, of doses are eligible for return. |
|Supersedes all previous returnable programs. Returns must be in full-pack quantities only. |
|Sanofi Pasteur |
|Trivalent |
|FLU040565 |Fluzone( High-Dose Influenza Virus Vaccine |$45.99** | Box |$459.90** | |
| |0.5mL prefilled syringes, needleless, 10 per box | |of 10 | | |
| |65 years of age and older (no preservatives or latex) | | | | |
| |
|FLU063115 |Fluzone( Quadrivalent Influenza Virus Vaccine |$15.014** |Vial |$150.14** | |
| |5mL 10-dose vial | | | | |
| |6 months of age and older (no latex) | | | | |
|FLU051925 |Fluzone( Quadrivalent Influenza Virus Vaccine |$16.208** | Box |$162.08** | |
| |0.25mL prefilled syringes, needleless, 10 per box | |of 10 | | |
| |6-35 months of age (no preservatives or latex) | | | | |
|FLU041950 |Fluzone( Quadrivalent Influenza Virus Vaccine |$16.208** | Box |$162.08** | |
| |0.5mL prefilled syringes, needleless, 10 per box | |of 10 | | |
| |6 months of age and older (no preservatives or latex) | | | | |
|FLU041910 |Fluzone( Quadrivalent Influenza Virus Vaccine |$16.208** | Box |$162.08** | |
| |0.5mL single-dose vials, 10 per box | |of 10 | | |
| |6 months of age and older (no preservatives or latex) | | | | |
|FLU071910 |Flublok( Quadrivalent Influenza Vaccine |$45.99** | Box |$459.90** | |
| |0.5mL prefilled syringes, 10 per box | |of 10 | | |
| |18 years and older | | | | |
| |(no eggs, influenza virus, preservatives, antibiotics or latex) | | | | |
|**Exclusive of Federal Excise Tax of $0.75 per dose |
|Sanofi Pasteur Returnability |
|Up to 25%, per presentation type, of doses are eligible for return. |
|Supersedes all previous returnable programs. Returns must be in full-pack quantities only. |
|Item No. |
|FLU089711 |FluLaval( Quadrivalent Infuenza Virus Vaccine |$15.02** |Vial |$150.20** | |
| |5mL 10-dose vial | | | | |
| |6 months of age and older (no latex) | | | | |
|FLU090652 |FluLaval( Quadrivalent Influenza Virus Vaccine |$16.07** | Box |$160.70** | |
| |0.5mL prefilled syringes, needleless, 10 per box | |of 10 | | |
| |6 months of age and older (no preservatives or latex) | | | | |
|FLU089652 |Fluarix( Quadrivalent Influenza Virus Vaccine |$16.07** | Box |$160.70** | |
| |0.5mL prefilled syringes, needleless, 10 per box | |of 10 | | |
| |6 months of age and older (no preservatives or latex) | | | | |
|**Exclusive of Federal Excise Tax of $0.75 per dose |
|GlaxoSmithKline Returnability |
| |
|Up to 30%, per presentation type, of doses are eligible for return. |
| |
|Supersedes all previous returnable programs. Returns must be in full-pack quantities only. |
|AstraZeneca |
|FLU030610 |FluMist( Quadrivalent Influenza Vaccine Live, Intranasal* |$21.803** | Box |$218.03** | |
| |0.2mL prefilled, single-use Intranasal spray | |of 10 | | |
| |2 years to 49 years of age (no preservatives or latex) | | | | |
|**Exclusive of Federal Excise Tax of $0.75 per dose |
| |
|2019-2020 Prebook Program for Flumist Quadrivalent |
|Prebook by June 30, 2019, to receive 5% off list price of $229.50 on all doses, included in above price. |
|Additional savings are available for accounts that prebook ≥400 doses. |
|Additional savings will be applied in the form of a rebate. 85% of the prebook volume must be delivered and accepted by December 31, 2019 to qualify for |
|rebates. |
|Rebates will be administered in the form of credit applied to accounts by June 30, 2020. |
| |
|On-Invoice Total Discount Net Discounted |
|Tier Doses Prebooked Discount Rebate % Off List Price Price** |
| |
|Base 10 – 399 doses 5% 0% 5% $218.03 |
|1 400 – 799 doses 5% 2% 7% $213.44 |
|2 800 – 1,199 doses 5% 4% 9% $208.85 |
|3 1,200 – 2,499 doses 5% 6% 11% $204.26 |
|4 2,500 – 4,999 doses 5% 8% 13% $199.67 |
|5 5,000 doses or greater 5% 10% 15% $195.08 |
| |
|AstraZeneca Returnability |
|Customers may return up to 25% of product purchased as long as they prebooked by June 30, 2019 and have accepted 85% of the prebooked volume by December 31, |
|2019. |
| |
|Supersedes all previous returnable programs. Returns must be in full-pack quantities only. |
|Total Order Quantity | |
|Orders can be cancelled or reduced on or before July 1, 2019. Cancellations may affect discounts, rebates and return policies. |
|Please refer to each manufacturer’s specific terms regarding discounts, rebates and return policies. |
|Complete and fax this form to FFF Enterprises: (800) 418-4333. Online orders are accepted through . |
|If you have any questions, contact Wow! Customer Service at (800) 843-7477. |
|Payment terms: 0.25% 20 days, net 60 days. |
|A confirmation with final confirmed pricing will be sent out to all customers for review, prior to shipment. |
|Customer represents warrants and agrees that Customer is purchasing products from FFF for its own use and use by its affiliated healthcare providers in |
|delivering services to patients and not for resale. Customer acknowledges that FFF is relying on this representation in making its decision to sell products to|
|Customer. |
|I have ordered the quantities listed above and agree to the terms that apply: | | |
| |Thank you for supporting FFF’s Guaranteed | |
|Authorized Signature: |Channel Integrity! | |
|Date: | | |
-----------------------
SOLD OUT
SOLD OUT
SOLD OUT
SOLD OUT
SOLD OUT
SOLD OUT*
*CONTACT YOUR SALES REP to place WAIT LIST orders, should more product become available.
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