2017-18 - PBA Health



|2019-2020 | | |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 |

|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 |

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|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 |

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|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: | | |

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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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