Addendum B document for 2009 renewal 112108

CMS-1380-IFC DKH 2/3/2021 2

Addendum B

The Centers for Medicare & Medicaid Services

Average Sales Price Data

Name of Drug or Biological Manufacturer (as “manufacturer” is defined in section 1927(k)(5) of the Social Security Act):

Legal Address:

Manufacturer Contact(s):

Name: Email:

Title: Fax:

Address: Telephone No.:

Name: Email:

Title: Fax:

Address: Telephone No.:

I certify that the reported Average Sales Prices were calculated accurately and that all information and statements made in this submission are true, complete, and current to the best of my knowledge and belief and are made in good faith. I understand that information contained in this submission may be used for Medicare reimbursement purposes.

Name of CEO, CFO or Authorizing Official:

Title:

__________________________ ____________________

Signature Date

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0921.

The time required to complete this information collection is estimated to average (40 hours) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

CMS 10110 approval pending

Expiration date: ___________.