Approval Request (1234)

All prices in local currency: EUR

Attachment 1.pdf
Attachment 2.xls
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Scope
Soliris PNH (1 / 30 / 300MG) - Hospital (public)
Prices
  List Price Mandatory Rebate Visible Net Price Negotiated Discount Non-Public Net Price   Other Commissions Arrangements In-Market Net Price Distributor Margin Transfer Price
Current 1,000 58.8 941.2 141.2 0.0   0.0 0.0 650 141.2  
Proposed 58.8 141.2   0.0 141.2
Visible
 
Discounts / Rebates / Fees
Current Proposed
Mandatory Rebate
0.00%
%
Negotiated Discount
0.00%
%
Other Commissions
0.00%
%
Distributor Margin
0.00%
%
Notes
Medicaid Additional State Level Rebates
Add State:
Alaska
0.00%
%
Arrangement(s)
Current Proposed
Patient Cost CAP
0.00 EUR
EUR
Revenue CAP
0.00 EUR
EUR
Free Of Charge
- in vials/months
3 months
- in value
0.00 EUR
EUR
Notes
Prices
  List Price Mandatory Rebate Visible Net Price Negotiated Discount Non-Public Net Price   Other Commissions Arrangements In-Market Net Price Distributor Margin Transfer Price
Current 1,000 58.8 941.2 141.2 0.0   0.0 0.0 650 141.2  
Proposed 58.8 141.2   0.0 141.2
Visible
 
Discounts / Rebates / Fees
Current Proposed
Mandatory Rebate
0.00%
%
Negotiated Discount
0.00%
%
Other Commissions
0.00%
%
Distributor Margin
0.00%
%
Notes
Medicaid Additional State Level Rebates
Add State:
Alaska
0.00%
%
Arrangement(s)
Current Proposed
Patient Cost CAP
0.00 EUR
EUR
Revenue CAP
0.00 EUR
EUR
Free Of Charge
- in vials/months
3 months
- in value
0.00 EUR
EUR
Notes
PNH
aHUS
Price Benchmark
1,000 EUR per vial
950 EUR per vial
1,200 EUR per vial
700 EUR per vial
Per vial
Soliris PNH (1 / 30 / 300MG) - Hospital (public)
List Price
EUR [USD]
Current Price 0.00 0.00
Proposed Price 0.00 0.00
In-Market Net Price
EUR [USD]
Current Price 0.00 0.00
Proposed Price 0.00 0.00
Net Realized Price
EUR [USD]
Current Price 0.00 0.00
 
Soliris PNH (1 / 30 / 300MG) - Retail (private)
List Price
EUR [USD]
Current Price 0.00 0.00
Proposed Price 0.00 0.00
In-Market Net Price
EUR [USD]
Current Price 0.00 0.00
Proposed Price 0.00 0.00
Net Realized Price
EUR [USD]
Current Price 0.00 0.00
Proposed Price 0.00 0.00
[Requestor Name]: Submitted

Requestor SUBMITTED on YYYY/MM/DD HH:MM EST

[Approver1 Name]: Approved

APPROVED on YYYY/MM/DD HH:MM EST

[Approver1 Name] Comment:
Looks good.

[Approver2 Name]: Rejected

REJECTED on YYYY/MM/DD HH:MM EST

[Approver2 Name] Comment:
This still needs work.

[Approver3 Name]: Pending

PENDING

Access Finalization
Price Finalization
Per vial
Soliris PNH (1 / 30 / 300MG) - Hospital (public)
  List Price Visible Net Price Non-Public Net Price   In-Market Net Price Transfer Price
Current 1,000 941.2 0.0   650  
Proposed 1,000 941.2 941.2   650 600
Visible
 
Effective Date
 
Soliris PNH (1 / 30 / 300MG) - Retail (private)
  List Price Visible Net Price Non-Public Net Price   In-Market Net Price Transfer Price
Current 1,000 941.2 0.0   650  
Proposed 1,000 941.2 941.2   650 600
Visible
 
Effective Date