2019-20 Influenza Vaccine Order Form

 Telephone FFF Account Number Order Placed By Customer's Special Instructions

2019-2020

Influenza Vaccine Order Form

Fax

Purchase Order Number

State License Number

Email Address

Ship To

Bill To

Attn:

Attn:

Date

A

GPO Affiliation

Item No.

Description

Dose

Seqirus

Trivalent

FLU001903

FluadTM Influenza Virus Vaccine 0.5mL prefilled syringes, needleless, 10 per box 65 years of age and older (no preservatives or latex)

$41.878**

Quadrivalent

FLU241910 FLU031901 FLU021920 FLU141910 FLU031903

Afluria Quadrivalent Influenza Virus Vaccine 5mL 10-dose vial 6 months of age and older (no latex)

SOLD OUT Afluria Quadrivalent Influenza Virus Vaccine

0.5mL prefilled syringes, needleless, 10 per box 3 years of age and older (no preservatives or latex)

SOLD OUT Afluria Quadrivalent Influenza Virus Vaccine

0.25mL prefilled syringes, needleless, 10 per box 6-35 months of age (no preservatives or latex)

Flucelvax Quadrivalent Influenza Virus Vaccine 5mL 10-dose vial 4 years of age and older (no antibiotics or latex)

Flucelvax Quadrivalent Influenza Virus Vaccine 0.5mL prefilled syringes, needleless, 10 per box

4 years of age and older (no preservatives, antibiotics or latex)

$13.533** $14.528** $14.528** $15.742** $16.90**

**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

Quadrivalent

Fluzone High-Dose Influenza Virus Vaccine 0.5mL prefilled syringes, needleless, 10 per box 65 years of age and older (no preservatives or latex)

$45.99**

FLU063115 FLU051925 FLU041950

SOLD OUT Fluzone Quadrivalent Influenza Virus Vaccine

5mL 10-dose vial 6 months of age and older (no latex) Fluzone Quadrivalent Influenza Virus Vaccine 0.25mL prefilled syringes, needleless, 10 per box 6-35 months of age (no preservatives or latex)

SOLD OUT Fluzone Quadrivalent Influenza Virus Vaccine

0.5mL prefilled syringes, needleless, 10 per box 6 months of age and older (no preservatives or latex)

$15.014** $16.208** $16.208**

FLU041910 FLU071910

SOLD OUT Fluzone Quadrivalent Influenza Virus Vaccine

0.5mL single-dose vials, 10 per box 6 months of age and older (no preservatives or latex) Flublok Quadrivalent Influenza Vaccine 0.5mL prefilled syringes, 10 per box 18 years and older (no eggs, influenza virus, preservatives, antibiotics or latex)

$16.208** $45.99**

**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.

U/M

Box of 10 Vial Box of 10 Box of 10 Vial Box of 10

Box of 10 Vial Box of 10 Box of 10 Box of 10 Box of 10

Price**

Qty. in Boxes or Vials

$418.78**

$135.33** $145.28** $145.28** $157.42** $169.00**

$459.90**

$150.14** $162.08** $162.08** $162.08** $459.90**

Rev 02252020

Item No.

Description

Dose

U/M

Price**

GlaxoSmithKline

SOLD OUT FluLaval Quadrivalent Infuenza Virus Vaccine

FLU089711

5mL 10-dose vial 6 months of age and older (no latex)

$15.02**? Vial $150.20**?

FLU090652

FluLaval Quadrivalent Influenza Virus Vaccine

SOLD OUT 0.5mL prefilled syringes, needleless, 10 per box

6 months of age and older (no preservatives or latex)

$16.07**?

Box of 10

$160.70**?

SOLD OUT FLU089652

Fluarix Quadrivalent Influenza Virus Vaccine 0.5mL prefilled syringes, needleless, 10 per box 6 months of age and older (no preservatives or latex)

$16.07**?

Box of 10

$160.70**?

**Exclusive of Federal Excise Tax of $0.75 per dose

? GSK contract pricing requires all members to be decked in the GSK system to qualify for the contract prices, as listed.

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,

SOLD OUT Intranasal*

0.2mL prefilled, single-use Intranasal spray

2 years to 49 years of age (no preservatives or latex)

$21.803**

Box of 10

$218.03**

Qty. in Boxes or Vials

**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.

Tier Doses Prebooked

On-Invoice Discount

Rebate

Total Discount % Off List Price

Net Discounted Price**

Base 10 ? 399 doses

5%

1

400 ? 799 doses

5%

2

800 ? 1,199 doses

5%

3

1,200 ? 2,499 doses

5%

4

2,500 ? 4,999 doses

5%

5

5,000 doses or greater

5%

0% 2% 4% 6% 8% 10%

5% 7% 9% 11% 13% 15%

$218.03 $213.44 $208.85 $204.26 $199.67 $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:

Authorized Signature:

Date:

Thank you for supporting FFF's Guaranteed Channel Integrity!

Rev 02252020

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