The information you provide will be kept confidential and will be used only for administering this Settlement. If you have any questions, please call the
Settlement Administrator at 1-877-221-7632.
A TPP Class Member or an authorized agent can complete this Claim Form. If both a Class Member and its authorized agent submit a Claim Form, the Settlement Administrator
will only consider the Class Member’s Claim Form. The Settlement Administrator may request supporting documentation. The claim may be rejected if any requested
documentation is not provided in a timely manner.
If you are a Class Member submitting a Claim Form on your own behalf, you must provide the information requested in “Part I, Section A – COMPANY OR HEALTH PLAN CLASS
MEMBER ONLY,” in addition to the other information requested by this Claim Form.
If you are an authorized agent of one or more Class Members, you must provide the information requested in “Part I, Section B – AUTHORIZED AGENT ONLY,” in addition
to the other information requested by this Claim Form.
You may submit a separate Claim Form for each Class Member, OR you may submit one Claim Form for all such Class Members as long as you provide the information
required for each Class Member on whose behalf you are submitting the form.
If you are submitting Claim Forms both on your own behalf as a Class Member AND as an authorized agent on behalf of one or more Class Members, you should submit
one Claim Form for yourself, completing Section A and another Claim Form or Forms as an authorized agent for the other Class Member(s), completing Section B.
Do not submit a Claim Form on behalf of any Class Member unless that Class Member provided prior authorization to submit the Claim Form.
In order to qualify to receive a payment from this Settlement, you must complete and submit this Proof of Claim form either on paper or electronically on the
Settlement website, and you may need to provide certain requested documentation to substantiate your Claim.
Your failure to complete and submit the Proof of Claim form postmarked or filed online by November 12, 2021, will prevent you from receiving any payment from this
Settlement. Submission of this Proof of Claim form does not ensure that you will share in the payments related to the Settlement. If the Settlement Administrator disputes
a material fact concerning your Claim, you will have the right to present information in a dispute resolution process.
CLAIM DOCUMENTATION REQUIREMENTS
You must provide all the information requested in “Part II: Amount Claimed.” You must submit claims data and information in support of the purchase amounts stated above
if your total net claim amount is more than $300,000. Your claimed purchase amounts of Brand or authorized generic EpiPens must be net of co-pays, deductibles, and
If you must submit claims data and information, it is mandatory that you provide the data for all categories listed below.
Affidavits that do not include the information
listed below will not be accepted
a) Unique patient identification number or code.
b) NDC Number (a list of NDC Numbers is included with this Proof of Claim form) – e.g., 00000-0000-00
c) Fill Date or Date of Service – e.g., 01/01/2007
d) Location (State) of Service – e.g., CA
e) Amount Billed (not including dispensing fee) – e.g., $40.00
f) Amount Paid by TPP net of co-pays, deductibles, and co-insurance – e.g., $20.00
If you are submitting a Proof of Claim form on behalf of multiple Class Members, also provide the following information for each prescription:
g) Plan or Group Name.
h) Plan or Group FEIN – provide group number for each transaction.
Information submitted will be covered by the Protective Order entered by the Court. For your convenience, an exemplar spreadsheet containing these categories is
available on this website. In addition, an Excel spreadsheet can be downloaded from the Settlement website, Please use this format if possible.
A list of the NDCs that will be considered by the Settlement Administrator is also available on this website.
If possible, please provide the electronic data in either Microsoft Excel format, ASCII flat file pipe “|”, tab-delimited, or fixed-width format.
Please contact the Settlement Administrator at 1-877-221-7632 with any questions about the required claims data.