Form 8947 - Report Of Branded Prescription Drug Information Page 5
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Form 8947 (Rev. 10-2011)
Page
Schedule D
Branded Prescription Drug Medicaid State Supplemental Rebates—Previously Reported NDCs (do not include National Drug Codes (NDCs)
or rebate information reported on Schedule B)
Entity name
If you have more rebate information to report than can be shown on this page,
complete and attach as many Schedules D as you need to list them all, numbering
Employer identification number (EIN).
Page
of
each page (for example, Page D1 of D5).
(b)
(b)
(b)
Medicaid state supplemental
Medicaid state supplemental
Medicaid state supplemental
(a)
(a)
(a)
rebate amount, if applicable
rebate amount, if applicable
rebate amount, if applicable
NDC
NDC
NDC
(if none, enter -0-)
(if none, enter -0-)
(if none, enter -0-)
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8947
Form
(Rev. 10-2011)
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