Thalomid and Revlimid Antitrust Litigation

THIRD PARTY PAYOR CLAIM FORM

ATTENTION: THIS FORM IS ONLY TO BE FILLED OUT ON BEHALF OF A THIRD-PARTY PAYOR, NOT INDIVIDUAL CONSUMERS

TO QUALIFY TO RECEIVE A PAYMENT FROM THIS SETTLEMENT, YOU MUST COMPLETE AND SUBMIT THIS CLAIM FORM.

Section A: General Information

The Claims Administrator will use this information for all communications regarding this Claim Form. If this information changes, you MUST notify the Claims Administrator in writing.


*By providing your email address, you authorize the Claims Administrator to use it in providing you with information relevant to this claim.

List all other names by which your company or health plan has been known and any other Federal Employer Identification Numbers ("FEINs") you have used before August 1, 2019.

Section B: Authorized Agent Only

Are you filing as an authorized agent?

Section C: Purchase Information

Provide the amount of money you spent on each drug for prescriptions filled before August 1, 2019 for use by your members, employees, insureds, participants, or beneficiaries in California, the District of Columbia, Florida, Kansas, Maine, Massachusetts, Michigan, Nebraska, New York, North Carolina, Oregon, Pennsylvania, Rhode Island, or Tennessee. Include purchases made on behalf of members located in one of these states, purchases processed in a department located in one of these states, or payments made to pharmacies located in one of these states.

$
$
Section D: Note Regarding Documentation

You do not need to provide any documentation at this time. However, the Claims Administrator may ask for additional proof of purchase.

Section E: Certification

I have read and am familiar with the contents of this Claim Form. I certify that the information provided by me is true, correct and complete to the best of my knowledge. I further certify that I am submitting this information on behalf of myself or a Settlement Class Member for whom I serve in the capacity of an authorized agent.

I hereby submit to the jurisdiction of the United States District Court for the District of New Jersey for all purposes connected with this Claim Form, including resolution of disputes relating to this Claim Form.

Required