CMS-10110 ASP Addendum macro

Proposed Revised Addendum A

Manufacturer's Name

NDC1

NDC2

NDC3

AlternateID

Manufacturer's
Average Sales
Price

Number of ASP
Units

Wholesale
Acquisition
Cost

Name of Drug or
Biological

Strength of the
Product

Volume
Per Item

Number of Items Expiration Date Date of First
Per NDC
of Final Lot Sold
Sale

Number of
CAP Units
Excluded

FDA
Application
Number

FDA
Application
Supplement
Number

Additional Additional FDA
FDA
Application
Application
Supplement
Number #1
Number #1

Additional
FDA
Application
Number #2

Additional FDA
Application
Supplement
Number #2

FDA Final
PreMarketing
Approval
Date

FDA
Approval
Type

Description
of FDA
Approval
Type