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PART II – AMOUNT CLAIMED

Please type or print in the box below, the total amount paid or reimbursed for Brand and authorized generic EpiPens, net of co‐pays, deductibles, and co‐insurance, between August 24, 2011, and November 1, 2020, inclusive.

Please note that certain groups have been excluded from the Class in this case. Do not submit a claim for or on behalf of any of the following excluded groups :

a. 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., Viatris, Inc., and their officers, directors, managers, employees, subsidiaries, and affiliates (collectively, the “Defendants”)

b. Government entities, other than government-funded employee benefit plans;

c. Fully insured health plans (i.e., plans that purchased insurance that covered 100% of the plan’s reimbursement obligations to its members);

d. Entities that purchased Branded or generic EpiPens directly from one or more of the Defendants;

e. All third-party payors who own or otherwise function as a Pharmacy Benefit Manager or control an entity who functions as a Pharmacy Benefit Manager; and

f. Any entity that previously opted out of the Class in this action.



Proof of Payment

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. Instructions on how to do so are found in the Claims Documentation Instructions on the Settlement Administrator’s website or included with this Claim Form. If your total net claim is $300,000 or less, you need not provide complete claims data with this Claim Form, but the Settlement Administrator may require supporting documentation after reviewing your Claim.


Please use the browse option, by clicking on “Select Files” in the box below to upload your supporting documentation.




Files To Be Uploaded Size Action


PART III – CERTIFICATION

I (We) have read and am (are) familiar with the contents of this Claim Form. I (We) certify that the information I (we) have set forth above and in any documents attached by me (us) are true, correct and complete to the best of my (our) knowledge. I (We) certify that I (we) of the Class Member(s) I (we) represent paid the total amount set forth above in out‐of‐pocket expenditures for purchases or reimbursements of Branded or generic EpiPens in the United States and its territories and possessions including Puerto Rico between August 24, 2011, and November 1, 2020, inclusive. I (We) further certify that I (we) or the Class Member(s) I (we) represent did not opt out of the certified Class in this Action. Nor did I (we) or the represented Class Member(s) purchase such EpiPens for purposes of resale. In addition, I (we): (1) have not (or the represented Class Member has not) served as counsel, officer, director, agent, or employee of one of the Defendants, or a corporate parent, subsidiary, affiliate, or other related entity thereof; and (2) did not purchase Branded or generic EpiPens directly from Defendants; and (3) do not own or otherwise function as a Pharmacy Benefit Manager or control an entity who functions as a Pharmacy Benefit Manager.

To the extent I (we) have been given authority to submit this Proof of Claim by a Class Member(s) on its 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(s) identified on a separate sheet of paper submitted with this form, and to the extent I (we) have been authorized to receive payment on behalf of this Class Member(s). In the event amounts from the Settlement Fund are distributed to me (us) and a Class Member(s) later claims that I (we) did not have authority to claim and/or receive such amounts on its behalf, I (we) and/or my (our) employer will hold the Class, counsel for the Class, and the Settlement Administrator harmless with respect to any claims made by the Class Member(s).

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