THIS WORKSHEET HAS BEEN COMPLETED FOR THE FOLLOWING TIME PERIOD:

PER UNIT

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$ AMOUNT
ORPERCENTAGE (%)

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$ AMOUNT
ORPERCENTAGE (%)

ESTIMATED NET COST RECOVERY

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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:

PER UNIT

Split Arrow

$ AMOUNT
ORPERCENTAGE (%)

Split Arrow

$ AMOUNT
ORPERCENTAGE (%)

ESTIMATED NET COST RECOVERY

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.