FEDERAL SUPPLY SCHEDULE

DEPARTMENT OF VETERANS AFFAIRS

NATIONAL ACQUISITION CENTER

FEDERAL SUPPLY SERVICE (049A2-2)

PHARMACEUTICAL TEAM

P.O. BOX 76, BLDG. 37 (1^st^ AVE, 1 BLOCK NORTH OF CERMAK RD.)

HINES, ILLINOIS 60141

REQUEST FOR MODIFICATION FORM

PRICE REDUCTION

For Federal Supply Schedules:

65, Part I, Section B -- Pharmaceuticals

[42-2A items ONLY]{.underline}

[PUBLIC LAW 102-585]{.underline}

[2009 UPDATES]{.underline}

Please use this form in conjunction with the Modification Clause
552.243-72, Generic Item Modifications, AS212 and EPA Clause 552.216-70
of your contract.

***[Please do not submit this cover page.]{.underline}***

You may submit this request for modification form(s) by scanning and
emailing to your assigned contracting officer, by faxing to (708)
786-4975 or 4974, or by submitting a hard copy via U.S. postal services
to your assigned contracting officer.

**Note**: Please note that the format has changed. Please read carefully
and follow the instructions for completing the modification
successfully. If all required material is not received, your Contracting
Officer may return your modification request with no additional action.

Company Name: **     **

Date **submitted** to VANAC: **     **

Contract No.: **V797P-      ** ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­

Special Item Number (SIN) Category: **42-2A**

Please indicate the type of decrease requested: *(Check all that apply)*

1.  If your firm has elected to maintain a [single]{.underline} annual
    FSS pricelist for its line items falling under Special Item Number
    42-2A,

> Decrease to FSS price

2.  If your firm has elected to maintain a [dual]{.underline} annual FSS
    pricelist for its line items falling under Special Item Number
    42-2A,

> Decrease to BIG4 price (which include VA, DoD, PHS including HIS,
> Coast Guard and State Veteran Homes who have sharing agreements with
> the VA under options 2, 3, or 4)
>
> Decrease to OGA price (All Other Government Agencies)

(See Price Reduction Clause 552.238-75 in your contract.)

A.  The requested price reduction is made for the following reason(s):
    *(Check all that apply)*

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1.   Voluntary, to Government only.

2.   Revised commercial catalog, price list, or other document upon
    which the contract award was predicated, to reduce prices.

3.   Granted more favorable discounts or terms and conditions than those
    contained in the commercial catalog, price list, or other documents
    upon which the contract award was predicated. Granted special
    discounts to the tracking customer that was the basis of award, and
    the change may have disturbed the ratio.

4.   In accordance with Public Law 102-585 for "covered drugs" only.

***[\*If 2, 3 or 4 is marked, please submit a copy of the applicable
catalog, price list, contractor bulletin, letter or customer agreement
which details the effective date, duration, terms and conditions of the
price reduction.]{.mark}***

B.  Indicate below if the price reduction being offered is temporary or
    permanent. If temporary, indicate the applicable time frame.

Permanent Temporary (Time Frame: *Begin* **[     ]{.underline}** *End*
[**     **)]{.underline}

C.  Indicate below if the reduced pricing is limited to specific
    eligible users of the FSS program.

> No Yes (If yes, indicate below the specific agencies entitled to the
> reduced price by checking the appropriate box)

+----------+---------+--------+--------+--------+---------+---------+
| **VA**   | *       | **C    | *      | *      | **IHS** | **      |
|          | *SVH2** | MOPs** | *DoD** | *BOP** |         | Other** |
+----------+---------+--------+--------+--------+---------+---------+
|          |         |        |        |        |         | **      |
|          |         |        |        |        |         |      ** |
+----------+---------+--------+--------+--------+---------+---------+

*[Legend:]{.underline}*

*SVH2 = Option 2 State Veterans Homes; CMOP = Consolidated Mail
Outpatient Pharmacy; DoD = Department of Defense; BOP = Bureau of
Prisons; IHS = Indian Health Service*

D.  **Complete your 2009 Public Law spreadsheet as stated in the
    instructional document and include with this modification:**

**Public Law Instructions.doc**

**[PUBLIC LAW 102-585 PRICING UPDATES]{.underline}**

A\) Provide a listing of all "covered drug" NDC numbers and proposed
price changes required/permitted by Public Law 102-585.

B\) Complete the following certification: ***(Please provide a signature
above printed name below)***

I, [**[     ]{.underline}**]{.mark} understand that the Public Law
calculated Federal Ceiling Price is the maximum price for an NDC and
that the Price Reduction Clause may cause the actual FSS selling price
to the Government to fall below the FCP. I have reviewed (a) my
commercial pricing and the price/discount relationship applicable to my
awarded tracking customer, and (b) the Price Reduction Clause with
regard to the maintenance of the established price/discount
relationship, and (c) I certify that the attached updated prices do not
adversely disturb the price/discount relationship established for this
FSS contract.

**PLEASE PROVIDE [AUTHORIZED]{.underline}**[^1] **SIGNATURE AND DATE
BELOW:**

[Signature of authorized Signatory]{.mark} [Date]{.mark}

**     **

Print Name and Title

***(To be completed by VA personnel)***

Approved Approved as Amended Disapproved

Signature of Contracting Officer Date Effective Date

**Prepared by:**

Signature of Contract Specialist (if applicable) Date CO Review

[^1]: An authorized signature is an individual listed in Block 6 or 7 of
    the Signatory Authority Form. No unauthorized signatures will be
    accepted.