W. Va. Code R. agency 206, tit. 206, ser. 206-01, app A
Please file your completed Appendix A with:
West Virginia Pharmaceutical Cost Management Council c/o West Virginia Department of Administration
Capitol Complex
1900 Kanawha Boulevard, East
Charleston, WV 25305
| Name of Reporting Entity |
| Reporting Period |
3.2.1. List below the total amount the reporting entity spent for advertising and direct promotion of prescription drugs to consumers, prescribers, pharmacies and patient support or advocacy groups within the State of West Virginia.
| Name of Reporting Entity | Amount Spent |
3.2.2. List below the total number of West Virginia prescribers to whom the reporting entity provided directly or indirectly, gifts, grants or payments of any kind in excess of one hundred dollars ($100.00) for the purpose of advertising prescription drugs.
| Annual Aggregate Amount of fees, food entertainment, recreational activities, travel expenses, gifts, grants or other payments | Total Number of Prescribers |
| $100.00-$2,500.00 | |
| $2,501,00-$5,000.00 | |
| $5,001.00-$7,500.00 | |
| $7,501.00-$10,000.00 |
3.2.3. List below the name of each prescription drug advertised by direct-to-consumer advertising which is directed at, received by or intended to be received by consumers in this state, the form of the advertising and the total amount expended for advertising each named prescription drug.
| Name of Drug (chemical name and brand name) | Form of Advertising | Total Expenditure on Advertising |
3.2.4. List below the name of any disease-specific patient support or advocacy group operating in this state to which the reporting entity made, directly or indirectly, gifts, grants or payments of any kind totaling $10,000 or more for the purpose of advertising prescription drugs and the total amount contributed to each named support group.
| Name of Advocacy Group | Amount of Payments |
3.2.5. List below the name of any pharmacy licensed in West Virginia to which the reporting entity made, directly or indirectly, gifts, grants or payments of any kind totaling $10,000 or more, for the purpose of advertising prescription drugs, the form of the advertising and the total amount contributed to each named pharmacy.
| Pharmacy | Type of Advertising | Amount of Payment |
I certify upon information and belief that the information contained on this form is true, correct and complete.
| Signature: |
| Printed Name: |
| Title: |
| Date: |
Taken, sworn and subscribed before me, this day of.....................
by............................................................
| Notary signature |
| Commission expires |
W. Va. Code R. agency 206, tit. 206, ser. 206-01, app A