Figure: 25 TAC §230.1(c)(2)(A)

Texas Department of Health
Bureau of Food and Drug Safety

Report of Actual Price Information from a Wholesale Drug Distributor

Actual price - The weighted median invoice price at which a wholesale distributor sells a prescription drug to Texas retail pharmacies from the first day of the month through the last day of the calendar month prior to the date of the request.

_________________________________________________________________________________________________________
(Name of licensee - identifying number)

Submits the following pricing information on the following drugs for the month and quarter of

______________________________________________:

National
Drug Code #
11 Char.

Name of
Drug
20 Char.

Name of Manufacturer
15 Char.

Form
Size
10 Char.

Unit
Size
10 Char.

Unit Strength
10 Char.

Wholesale
Distributor
Actual Price
10 Char.