Lidoderm 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.

PART I - CLAIMANT IDENTIFICATION

Personal Information
Filing Option
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Section B: Should I File a Claim Form?

You (or the class member(s) on whose behalf you are submitting this form) must meet the following criteria to be eligible for a payment from the Proposed Settlements:

  • Entity in the United States and its territories;
  • Paid and/or provided reimbursements for some or all of the purchase price of (i) branded Lidoderm during the time period from August 23, 2012 through September 14, 2013, and/or (ii) AB-rated generic Lidoderm (Lidocaine 5% patch) during the time period from September 15, 2013 through August 1, 2014;
  • For consumption by the insureds, plan participants or beneficiaries of you or the class member on whose behalf you are submitting this form (i.e. not for resale); and
  • In one or more of the following states: Arizona, California, Florida, Kansas, Maine, Massachusetts, Minnesota, Nevada, New Hampshire, New Mexico, New York, North Carolina, North Dakota, South Dakota, Tennessee, West Virginia, or Wisconsin (the Class States).

Excluded from the Class and from the Proposed Settlements are:

  • Subsidiaries and affiliates of defendants Endo Pharmaceuticals Inc. ("Endo"); Teikoku Pharma USA, Inc. or Teikoku Seiyaku Co., Ltd. (together, "Teikoku"); or Actavis, Inc. (f/k/a Watson Pharmaceuticals, Inc.), Watson Laboratories, Inc., Actavis plc, Anda Inc., Anda Pharmaceuticals, Inc., or Valmed Pharmaceuticals, Inc. (together, "Watson");
  • Fully insured health plans (i.e., a plan that purchased insurance that covered 100 percent of the plan’s reimbursement obligations to all of its members);
  • Government entities, other than government-funded employee benefit plans;
  • Pharmacy benefit managers; and
  • Entities that previously excluded themselves from the class and have not requested to opt back in.

Required