Request for Approved Ex-manufacturer Price                                               PB11a

(price agreed under section 85AD or determined under section 85B of the National Health Act 1953)	

Instructions for completing a PB 11a form are available on the PBS website at http://www.pbs.gov.au/info/industry/useful-resources/pbs-forms

Responsible Person
(s84AF of the Act)		Responsible Person’s Authorised Representative:	
		•	Name		
Responsible Person’s
Full Postal Address		•	Telephone (Direct)		
		•	E-mail address		

Drug: 	Requested Effective Date:	
PBS
Code 

	Form (including strength)
	Manner of Admin	Brand

	Pricing Quantity

	Price for Agreement or Determination
(Ex-man price for pricing quantity)
(AEMP)	Manu-facturer’s PBS Pack
Sizes
 	Proportional Ex-manufacturer Price for other pack sizes
(PEMP)	Price Claimed by
Responsible Person (Ex-Man for pack size) 
(where applicable)	Comment	

	
The Responsible Person requests:
A)	agreement to the price in the ‘Price for Agreement or Determination’ column in the table above where:
•	there is no Price Claimed for the pricing quantity, and the responsible person has a pack size equal to that quantity; or 
•	the responsible person does not have a pack size equal to the pricing quantity, and there is at least one Manufacturer’s PBS Pack Size that does not have a Price Claimed;
B)	a price premium/special patient contribution for pack sizes for which the Price Claimed is completed.

Signature (Responsible Person’s Authorised Representative mentioned above): ________________________________________   Date: _________________
  
For Department of Health completion only:	
Pricing accords with amount negotiated and recommended for agreement	Signed:		Date:		
Comments (if any):