Common use of Sample Receipt Forms Clause in Contracts

Sample Receipt Forms. Sample Receipt Forms utilized by Impax for distribution of Samples under this Agreement shall contain the following information: • Sample Receipt Number • PSR ID Number • PSR Name • Sales Territory Number • Call Date • Prescriber Information • Name [Last, First, Middle Initial] • Address • Professional Designation [MD, DO, NP, PA, Other (specify)] • State License Number • Product Information • Product Name [e.g., XXXXX] • Dosage Strength/Package Size [e.g., 50mg (1 x 7)] • NDC Number [e.g., 1211-40] • Manufacturing Lot Number • Quantity distributed • Practioner Signature • PSR Signature • The following disclosure language immediately under the Practioner Signature: • “By signing, I certify: I am a licensed practitioner and can legally prescribe in my state; if my authority is dependent, I have a current collaborative agreement that includes the samples requested. I am requesting samples so I may evaluate the efficacy & tolerability in an appropriate patient. These samples will not be traded, sold, offered for sale, bartered, or returned for credit, nor be submitted to any public or private third-party payor for reimbursement. This is my personal signature.” Initial Training - XXXXX. POA Training - XXXXX. New Hire Training - XXXXX. þ Total Prescriptions in XXXXX Category (All Prescribers) ▇▇▇▇▇ ▇▇▇▇▇ XXXXX TRx — All Prescribers ▇▇▇▇▇ ▇▇▇▇▇ XXXXX Market Share — All Prescribers XXXXX% XXXXX% XXXXX% Total Prescriptions in XXXXX Category By Target Neurologists ▇▇▇▇▇ ▇▇▇▇▇ XXXXX TRx — Target Neurologists ▇▇▇▇▇ ▇▇▇▇▇ XXXXX Market Share — Target Neurologists XXXXX% XXXXX% XXXXX% Incremental Market Share (amount by which increase in Target Neurologist Market Share for XXXXX exceeds increase in Market Share for XXXXX for all prescribers) XXXXX% Incremental Prescriptions by Target Neurologists above Baseline (Incremental Market Share times Total Prescriptions in XXXXX Category By Target Neurologists) XXXXX Average Selling Price per Tablet for XXXXX tablets $▇▇▇▇▇ ▇▇▇▇▇ tablets per TRx XXXXX Value of each XXXXX TRx $XXXXX Incremental Net Sales (Net Sales resulting from Target Neurologist TRxs above baseline) $XXXXX Incentive Fee: 15% of Incremental Net Sales $XXXXX Market Share for XXXXX for all prescribers is calculated for Contract Year 1 and Contract Year 2 as shown above. Market Share for all prescribers increased XXXXX% from year 1 to year 2 (XXXXX% - XXXXX%). The same calculation is done for the Target Neurologist Market Share. This calculation shows market share for the target neurologists increased by XXXXX% (to XXXXX% from XXXXX%). The calculation shows that Target Neurologist Market Share increased by XXXXX % (XXXXX % — XXXXX %) more than the increase in Market Share for all prescribers. A XXXXX % increase in Target Neurologist Market Share translates into an incremental increase in TRxs of XXXXX (XXXXX * XXXXX%). From Wyeth’s internal sales reporting system, Wyeth calculates that the average net selling price per tablet of XXXXX during this year is $ XXXXX per tablet and Wyeth has determined that a TRx of XXXXX contains 30 tablets, hence, each TRx of XXXXX is worth $XXXXX ($XXXXX * XXXXX) of Net Sales value. The incremental increase in prescriptions for XXXXX obtained from Targeted Neurologists above the general increase therefore results in Incremental Net Sales of $XXXXX (XXXXX * $XXXXX). Impax is paid an incentive fee of XXXXX% of this amount or $XXXXX for the Contract Year.

Sample Receipt Forms. Sample Receipt Forms utilized by Impax for distribution of Samples under this Agreement shall contain the following information: • Sample Receipt Number • PSR ID Number • PSR Name • Sales Territory Number • Call Date • Prescriber Information • Name [Last, First, Middle Initial] • Address • Professional Designation [MD, DO, NP, PA, Other (specify)] • State License Number • Product Information • Product Name [e.g., XXXXXPristiq Tablets] • Dosage Strength/Package Size [e.g., 50mg (1 x 7)] • NDC Number [e.g., 1211-40] • Manufacturing Lot Number • Quantity distributed • Practioner Signature • PSR Signature • The following disclosure language immediately under the Practioner Signature: • “By signing, I certify: I am a licensed practitioner and can legally prescribe in my state; if my authority is dependent, I have a current collaborative agreement that includes the samples requested. I am requesting samples so I may evaluate the efficacy & tolerability in an appropriate patient. These samples will not be traded, sold, offered for sale, bartered, or returned for credit, nor be submitted to any public or private third-party payor for reimbursement. This is my personal signature.” Initial Training - XXXXX. POA Training - XXXXX. New Hire Training - XXXXX. þ Total Prescriptions in XXXXX Antidepressant Category (All Prescribers) ▇▇▇▇▇ ▇▇▇▇▇ XXXXX Pristiq TRx — All Prescribers ▇▇▇▇▇ ▇▇▇▇▇ XXXXX Pristiq Market Share — All Prescribers XXXXX% XXXXX% XXXXX% Total Prescriptions in XXXXX Antidepressant Category By Target Neurologists ▇▇▇▇▇ ▇▇▇▇▇ XXXXX Pristiq TRx — Target Neurologists ▇▇▇▇▇ ▇▇▇▇▇ XXXXX Pristiq Market Share — Target Neurologists XXXXX% XXXXX% XXXXX% Incremental Market Share (amount by which increase in Target Neurologist Market Share for XXXXX Pristiq exceeds increase in Market Share for XXXXX Pristiq for all prescribers) XXXXX% Incremental Prescriptions by Target Neurologists above Baseline (Incremental Market Share times Total Prescriptions in XXXXX Antidepressant Category By Target Neurologists) XXXXX Average Selling Price per Tablet for XXXXX Pristiq tablets $▇▇▇▇▇ ▇▇▇▇▇ XXXXX Pristiq tablets per TRx XXXXX Value of each XXXXX Pristiq TRx $XXXXX Incremental Net Sales (Net Sales resulting from Target Neurologist TRxs above baseline) $XXXXX Incentive Fee: 15% of Incremental Net Sales $XXXXX Market Share for XXXXX Pristiq for all prescribers is calculated for Contract Year 1 and Contract Year 2 as shown above. Market Share for all prescribers increased XXXXX% from year 1 to year 2 (XXXXX% - XXXXX%). The same calculation is done for the Target Neurologist Market Share. This calculation shows market share for the target neurologists increased by XXXXX% (to XXXXX% from XXXXX%). The calculation shows that Target Neurologist Market Share increased by XXXXX % (XXXXX % — XXXXX %) more than the increase in Market Share for all prescribers. A XXXXX % increase in Target Neurologist Market Share translates into an incremental increase in TRxs of XXXXX (XXXXX * XXXXX%). From Wyeth’s internal sales reporting system, Wyeth calculates that the average net selling price per tablet of XXXXX Pristiq during this year is $ XXXXX per tablet and Wyeth has determined that a TRx of XXXXX Pristiq contains 30 tablets, hence, each TRx of XXXXX Pristiq is worth $XXXXX ($XXXXX * XXXXX) of Net Sales value. The incremental increase in prescriptions for XXXXX Pristiq obtained from Targeted Neurologists above the general increase therefore results in Incremental Net Sales of $XXXXX (XXXXX * $XXXXX). Impax is paid an incentive fee of XXXXX% of this amount or $XXXXX for the Contract Year.