CMS-10110 Addendum B

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

PRA Disclosure Statement
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 09380921 (Expires XX/XX/XXXX). The time required to complete this information collection is estimated to average 13
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 Disclosure**** Please do not send
applications, claims, payments, medical records or any documents containing sensitive information to the PRA
Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden
approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained.