"Naloxone Rebate Request Form for Government or Public Entitles" - Delaware

Naloxone Rebate Request Form for Government or Public Entitles is a legal document that was released by the Delaware Department of Justice - a government authority operating within Delaware.

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Download "Naloxone Rebate Request Form for Government or Public Entitles" - Delaware

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Attorney General Matthew P. Denn
Department of Justice Consumer Protection Unit
820 N. French Street, 5th Floor
Wilmington, DE 19801
www.attorneygeneral.delaware.gov
Naloxone Rebate Request Form
Naloxone Rebate Request Form
Naloxone Rebate Request Form
Naloxone Rebate Request Form
for Government or Public Entities in
for Government or Public Entities in
for Government or Public Entities in
for Government or Public Entities in
the
the State of Delaware
the
the
State of Delaware
State of Delaware
State of Delaware
Name: ________________________________________________________________________
First
Last
Title
Agency: ______________________________________________________________________
Address: ______________________________________________________________________
City
State
Zip Code
Phone: ___________________________
Email: ____________________________________
I certify on behalf of _________________________________ that the attached invoices or
Agency
other documentation represent purchases of or reimbursements for Amphastar naloxone
syringes by ______________________________ purchased between _______and _______.
Agency
Date
Date
is not seeking a rebate for syringes for which it has
____________________________________________
Agency
received reimbursements for the costs of that syringe from any other government or public
entity in the State of Delaware.
_____________________________________
_______________________
Signature
Date
For more information or any questions about the rebate program, please contact Shannon Faulk
at Shannon.Faulk@state.de.us or (302) 577-8600.
Attorney General Matthew P. Denn
Department of Justice Consumer Protection Unit
820 N. French Street, 5th Floor
Wilmington, DE 19801
www.attorneygeneral.delaware.gov
Naloxone Rebate Request Form
Naloxone Rebate Request Form
Naloxone Rebate Request Form
Naloxone Rebate Request Form
for Government or Public Entities in
for Government or Public Entities in
for Government or Public Entities in
for Government or Public Entities in
the
the State of Delaware
the
the
State of Delaware
State of Delaware
State of Delaware
Name: ________________________________________________________________________
First
Last
Title
Agency: ______________________________________________________________________
Address: ______________________________________________________________________
City
State
Zip Code
Phone: ___________________________
Email: ____________________________________
I certify on behalf of _________________________________ that the attached invoices or
Agency
other documentation represent purchases of or reimbursements for Amphastar naloxone
syringes by ______________________________ purchased between _______and _______.
Agency
Date
Date
is not seeking a rebate for syringes for which it has
____________________________________________
Agency
received reimbursements for the costs of that syringe from any other government or public
entity in the State of Delaware.
_____________________________________
_______________________
Signature
Date
For more information or any questions about the rebate program, please contact Shannon Faulk
at Shannon.Faulk@state.de.us or (302) 577-8600.
Attorney General Matthew P. Denn
Department of Justice Consumer Protection Unit
820 N. French Street, 5th Floor
Wilmington, DE 19801
www.attorneygeneral.delaware.gov
Naloxone Rebate Instructions
Naloxone Rebate Instructions
Naloxone Rebate Instructions
Naloxone Rebate Instructions
On September 17, 2015, Delaware Attorney General Mathew P. Denn entered into an agreement with
Amphastar Pharmaceuticals, Inc. Under the agreement, the drug manufacturer agreed to provide a $4
rebate to a government or public entity in the State of Delaware for each Amphastar naloxone syringe it
purchased during the time period September 18, 2015 through September 17, 2016, or for a reimbursement
the entity made for such a purchase during that time period. This agreement has since been amended to
increase the rebate amount to $6 and extend the purchase period through September 17, 2017. A copy of
the agreement and amendment can be found at
http://www.attorneygeneral.delaware.gov/fraud/cpu/documents/DE_Payment_Agreement_091715.pdf.
Eligibility
Eligibility
Eligibility
Eligibility
All government or public entities in the State of Delaware are eligible to receive rebate payments.
The agency is not required to purchase the syringe directly from Amphastar to receive the rebate.
An eligible purchase also includes purchases made from wholesalers and retailers.
An agency purchase where the agency received reimbursement for the costs of the syringe from
another government or public entity in the State of Delaware is not eligible for a rebate.
Only purchases of Amphastar-manufactured naloxone syringes made between September 18, 2015
through September 17, 2017 are eligible for the rebate payment. This includes the Luer-Jet prefilled
syringe labeled with the National Drug Code # 76329-3369-1.
Submission Requirements
Submission Requirements
Submission Requirements
Submission Requirements
An agency seeking a rebate must submit a written accounting certifying the number of naloxone
syringes purchased or reimbursed by the agency during a three month time period.
The submission must include paid invoices or other reasonably adequate documentation of the
number of syringes purchased.
Each submission must be made within sixty (60) days of the conclusion of the calendar quarter the
purchase or reimbursement was made.
A claim form is attached for your convenience.
The claim form and supporting documentation should be submitted to Melissa Suarez, Amphastar,
Manager, Sales and Marketing at MelissaS@Amphastar.com.
Rebate Reimbursement Information
Rebate Reimbursement Information
Rebate Reimbursement Information
Rebate Reimbursement Information
Under the agreement, Amphastar is required to provide the payment within 90 business days of receiving an
agency’s claim form. Payment may take significantly longer if 10 or more separate agencies request rebates
in a given quarter. If you have any questions about the rebate process, please contact Shannon Faulk with
the Delaware Department of Justice at (302) 577-8600 or Melissa Suarez with Amphastar at (909) 942-4182.
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