In re EpiPen Marketing, Sales Practices and Antitrust Litigation

Section A: Claimant Identification

Claimant's Name: *

Agent/Legal Representative (if any):

Street Address: *

City: *

State: *

Zip: *

Mobile Telephone Number: *

Email Address: *

* By providing your e-mail address, you authorize the Settlement Administrator to use it in providing you with information relevant to this claim.

Unless you affirmatively select alternative means for payment, all settlement payments will be digitally sent to you via email. Please ensure you provide a current, valid email address and mobile phone number with your claim submission. If the email address or mobile phone number you include with your submission becomes invalid for any reason, it is your responsibility to provide accurate contact information to the Settlement Administrator to receive a payment. When you receive the email and/or mobile phone text notifying you of your Settlement payment, you will be provided with a number of digital payment options such as PayPal, Venmo, Apple Pay, Amazon, or direct deposit, to immediately receive your settlement payment. The email and/or text will also give you the option to request a paper check.

Section B: Should I File a Claim Form?

In order to be eligible to file a claim form and receive a cash distribution from the proposed Settlement, you must be a person or entity in the United States who paid or provided reimbursement for some or all of the purchase price of Branded or authorized generic EpiPens for the purpose of consumption, and not resale, by yourself or your family member(s) at any time between August 24, 2011, and November 1, 2020.

Several groups are excluded from the Class and are not eligible to file a claim form and receive a cash distribution from the proposed Settlement, even if they otherwise meet the definition above. The following groups are excluded from Class:

a. Any person or entity who is an officer, director, manager, employee, subsidiary, or affiliate; of Pfizer Inc., Meridian Medical Technologies, Inc., King Pharmaceuticals, Inc. (n/k/a King Pharmaceuticals LLC), Mylan N.V., Mylan Specialty L.P., Mylan Pharmaceuticals Inc., or Viatris Inc. (together, the “Defendants”);

b. Insured consumers who purchased Branded or generic EpiPens only via a fixed dollar co-payment that is the same for all covered devices, whether Branded or generic, regardless of the price of the device (e.g., $20 for all Branded and generic devices);

c. Consumers who purchased or received Branded or generic EpiPens only through a Medicaid program;

d. Consumers who only purchased Branded or generic EpiPens directly from one or more of the Defendants;

e. Any of the judges in this case and members of their immediate families;

f. Consumers whose only purchases of an EpiPen occurred before March 13, 2014, and;

g. Any person who has previously opted out of the Class in this case.

By checking this box, I confirm that I have read the definition of the Class and I am not excluded from participating in the proposed Settlement. *

Section C: Purchase Information

Provide the total number of EpiPens that you purchased AND the total amount of your out‐of‐pocket expenditures for purchases or reimbursement of Branded or generic EpiPens between August 24, 2011, and November 1, 2020:

Number of Branded and generic EpiPens purchased between August 24, 2011 and November 1, 2020:

Total amount of out-of-pocket expenditures you paid for the EpiPen purchases identified above:

Were the EpiPen purchases identified above made using some form of insurance benefit that covered some of the costs of those purchases: * (please select one).

Yes No

Section D: Note Regarding Documentation

You do not need to provide any documentation at this time. However, the Settlement Administrator may ask for additional proof supporting your claim. Any one of the following is acceptable as claim documentation for the purchase information set forth in Section C above, if requested by the Settlement Administrator:

1. Itemized receipts, cancelled checks, or credit card statements that show payment(s) for Branded or generic EpiPens; or

2. An EOB (explanation of benefits) from your insurer that shows you paid for Branded or generic EpiPens; or

3. Records from your pharmacy showing that you paid for Branded or generic EpiPens; or

4. Copies of records showing prescriptions written for Branded or generic EpiPens.

Section E: Certification

I have read and am familiar with the contents of this Proof of Claim. I certify that the information I have set forth above is true, correct and complete to the best of my knowledge. I certify that I, or the Class Member I represent, paid the total amount set forth above in out‐of‐pocket expenditures for purchases or reimbursements of Branded or authorized generic versions of EpiPen prescriptions between August 24, 2011, and November 1, 2020, inclusive. I further certify that I, or the Class Member I represent, did not opt out of the certified Class in this Action. Nor did I, or the Class Member I represent, purchase such Branded or authorized generic versions of EpiPen for purposes of resale.

In addition, I: (1) have not (or the represented Class Member has not) served as counsel, officer, director, agent, or employee of any of the Defendants, or a corporate parent, subsidiary, affiliate, or other related entity thereof; (2) did not only purchase Branded or generic EpiPens via a fixed dollar co-payment that is the same for all covered devices, whether branded or generic (e.g., $20 for all branded and generic devices); (3) did not purchase or receive Branded or generic EpiPens only through a Medicaid program; (4) did not purchase Branded or generic EpiPens directly from Defendants; (4) am not one of the judges in this case or a member of their immediate families; and (5) did not only purchase a Branded or generic EpiPen before March 13, 2014.

To the extent I have been given authority to submit this Proof of Claim by a Class Member on his or her behalf, and accordingly am submitting this Proof of Claim in the capacity of an Authorized Agent with authority to submit it by the Class Member identified on a separate sheet of paper submitted with this form, and to the extent I have been authorized to receive on behalf of this Class Member(s) any and all amounts that may be allocated to him or her from the Settlement Fund, I certify that such authority has been properly vested in me and that I will fulfill all duties I may owe the Class Member. In the event amounts from the Settlement Fund are distributed to me and a Class Member later claims that I did not have the authority to claim and/or receive such amounts on its behalf, I and/or my employer will hold the Class, counsel for the Class, and the Settlement Administrator harmless with respect to any claims made by the Class Member.

I hereby submit to the jurisdiction of the United States District Court for the District of Kansas for all purposes connected with this Proof of Claim, including resolution of disputes relating to this Proof of Claim. I acknowledge that any false information or representations contained herein may subject me to sanctions, including the possibility of criminal prosecution. I agree to supplement this Proof of Claim by furnishing documentary backup for the information provided herein, upon request of the Settlement Administrator.

Claimant Signature: *