rsv | BluPax

ITEM #	NDC	DESCRIPTION	PRESENTATION	WAC
117499	80777-0345-96	mRESVIA Respiratory Syncytial Virus Vaccine, mRNA, 0.5mL Single Dose Pre-Filled Syringe, Age 60y+	One Pre-Filled Syringe Box of Ten (10 doses)	$2,900/box we can service your direct contract with Moderna

Quantity Needed:*

One unit of 10 doses acknowledgment Required field

I understand that one unit ordered contains a box of 10 doses.

Non-returnable acknowledgment Required field

I understand that due to the cold-chain logistics associated with the vaccine, this order is non-returnable.

Person Filling This Form:*

Pharmacy Name:*

Pharmacy Account Number:*

National Account Manager: