Figure: 25 TAC §230.1(c)(2)(B)

Texas Department of Health
Bureau of Food and Drug Safety

Report of Average Manufacturer Price Information from a Manufacturer

Average manufacture price - The average price paid to the manufacturer for a prescription drug in the United States by wholesalers for prescription drugs distributed to the retail pharmacy class of trade, after deducting customary prompt pay discounts, calculated for the most recent required quarterly report to the Secretary of Health and Human Services.

Manufacturer shall represent and warrant that its submission of the average manufacturer price is that which was reported to the United States Secretary of Health and Human Services for the most recently required quarterly report under 42 U.S.C. 1396r-8(k). A submission to the council of the identical data reported to the Secretary in such report shall be conclusive for purposes of this statute.

_________________________________________________________________________________________________________
(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.

Average
Manufacturer
Price
10 Char.