This worksheet is designed to help you conduct a side-by-side estimate of the net cost recovery for up to 3 products or 3 payers. Fill in all required fields with the appropriate information to calculate the estimated net cost recovery.

THIS WORKSHEET HAS BEEN COMPLETED FOR THE FOLLOWING TIME PERIOD:

PER UNIT

$ AMOUNT
ORPERCENTAGE(%)

$ 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.

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