2020-2021 - PBA Health



|2020-2021 | | |Date |

|PBA Influenza Vaccine ORDER FORM | | | |

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| | | |Contract Affiliation |

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|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:       |

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|Item No. |

|Trivalent |

|FLU002003 |Fluad® Influenza Virus Vaccine |$45.107** | Box |$451.07** |      |

| |0.5mL prefilled syringes, needleless, 10 per box | |of 10 | | |

| |65 years of age and older (no preservatives or latex) | | | | |

|Quadrivalent |

|FLU242010 |Afluria® Quadrivalent Influenza Virus Vaccine |$14.362** |Vial |$143.62** |      |

| |5mL 10-dose vial | | | | |

| |6 months of age and older (no latex) | | | | |

|FLU032001 |Afluria® Quadrivalent Influenza Virus Vaccine |$15.418** | Box |$154.18** |      |

| |0.5mL prefilled syringes, needleless, 10 per box | |of 10 | | |

| |3 years of age and older (no preservatives or latex) | | | | |

|FLU022020 |Afluria® Quadrivalent Influenza Virus Vaccine |$15.418** | Box |$154.18** |      |

| |0.25mL prefilled syringes, needleless, 10 per box | |of 10 | | |

| |6-35 months of age (no preservatives or latex) | | | | |

|FLU142010 |Flucelvax® Quadrivalent Influenza Virus Vaccine |$17.686** |Vial |$176.86** |      |

| |5mL 10-dose vial | | | | |

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

|FLU032003 |Flucelvax® Quadrivalent Influenza Virus Vaccine |$18.987** | Box |$189.87** |      |

| |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 |

|Quadrivalent |

|FLU012065 |Fluzone® High-Dose Quadrivalent Influenza Virus Vaccine |$50.353** | Box |$503.53** |      |

| |0.7mL prefilled syringes, needleless, 10 per box | |of 10 | | |

| |65 years of age and older (no preservatives or latex) | | | | |

|FLU063315 |Fluzone® Quadrivalent Influenza Virus Vaccine |$15.314** |Vial |$153.14** |      |

| |5mL 10-dose vial | | | | |

| |6 months of age and older (no latex) | | | | |

|FLU042050 |Fluzone® Quadrivalent Influenza Virus Vaccine |$16.534** | Box |$165.34** |      |

| |0.5mL prefilled syringes, needleless, 10 per box | |of 10 | | |

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

|FLU042010 |Fluzone® Quadrivalent Influenza Virus Vaccine |$16.534** | Box |$165.34** |      |

| |0.5mL single-dose vials, 10 per box | |of 10 | | |

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

|FLU072010 |Flublok® Quadrivalent Influenza Vaccine |$50.353** | Box |$503.53** |      |

| |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. |

|FLU081652 |FluLaval® Quadrivalent Influenza Virus Vaccine |$16.552** | Box |$165.52** |      |

| |0.5mL prefilled syringes, needleless, 10 per box | |of 10 | | |

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

|FLU088552 |Fluarix® Quadrivalent Influenza Virus Vaccine |$16.552** | Box |$165.52** |      |

| |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 |

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|Up to 30%, per presentation type, of doses are eligible for return. |

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|Supersedes all previous returnable programs. Returns must be in full-pack quantities only. |

|AstraZeneca |

|FLU030710 |FluMist® Quadrivalent Influenza Vaccine Live, Intranasal* |$20.196** | Box |$201.96** |      |

| |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 |

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|2020-2021 Prebook Program for Flumist Quadrivalent |

|Prebook by January 15, 2020, to receive 12% off list price of $229.50 on all doses, included in above price. Orders prebooked from January 16, 2020 to March |

|31, 2020 receive 8% discount. In-season orders placed on or after April 1, 2020 receive 5% discount. |

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|AstraZeneca Returnability |

|Customers may return up to 25% of product purchased as long as they prebooked by March 31, 2020 and have accepted 85% of the prebooked volume by December 31, |

|2020. |

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|Customers who accept 85% of prebook, and a minimum of 40 doses, are eligible for low returns rebate of 2%. Applicable with returns of 10%, or less, of accepted|

|product. |

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|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, 2020. 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: | | |

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