Know The Net Cost

THIS WORKSHEET HAS BEEN COMPLETED FOR THE FOLLOWING TIME PERIOD:

PRODUCT

PAYER

NUMBER OF INDUCTION DOSES PER PATIENT*

AVERAGE UNITS PER INDUCTION DOSE*

AVERAGE NUMBER OF PATIENTS WHO UNDERGO INDUCTION EACH YEAR*

PER UNIT

ACQUISITION COST*

DISCOUNT PER UNIT*

$ AMOUNT
ORPERCENTAGE (%)

DISCOUNT PER UNIT*

REBATE PER UNIT*

$ AMOUNT
ORPERCENTAGE (%)

REBATE PER UNIT*

REIMBURSEMENT*

ESTIMATED NET COST RECOVERY^†

PER UNIT

PER PATIENT

PER YEAR, TOTAL

Please refresh your screen to clear the worksheet and start again.

This information is not a promise of coverage or payment. It is not intended to give reimbursement advice or increase reimbursement by any payer. Legal requirements and plan information can be updated frequently. Contact the plan for more information about current coverage, reimbursement policies, restrictions, or requirements that may apply.

*Required field.
^†Assumes that product administration occurred within the same quarter as product purchase.

THIS WORKSHEET HAS BEEN COMPLETED FOR THE FOLLOWING TIME PERIOD:

PRODUCT

PAYER

AVERAGE UNITS/TREATMENT*

TREATMENTS PER QUARTER*

AVERAGE NUMBER OF PATIENTS TREATED PER QUARTER*

PER UNIT

ACQUISITION COST*

DISCOUNT PER UNIT*

$ AMOUNT
ORPERCENTAGE (%)

DISCOUNT PER UNIT*

REBATE PER UNIT*

$ AMOUNT
ORPERCENTAGE (%)

REBATE PER UNIT*

REIMBURSEMENT*

ESTIMATED NET COST RECOVERY^†

PER UNIT

PER TREATMENT

PER QUARTER

PER YEAR

Please refresh your screen to clear the worksheet and start again.

*Required field.
^†Assumes that product administration occurred within the same quarter as product purchase.

PER UNIT

ESTIMATED NET COST RECOVERY†

PER UNIT

ESTIMATED NET COST RECOVERY†

ESTIMATED NET COST RECOVERY^†

ESTIMATED NET COST RECOVERY^†