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 May 20, 2020.
Are you filing as an authorized agent?
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 at the address above.
* As an Authorized Agent, please select how your relationship with the Settlement Class Member(s) is best described:
Please list the name, address and FEIN of every Class Member (i.e., Company or Health Plan) for whom you have been duly authorized to
submit this Claim Form (attach additional sheets to this Claim Form as necessary). Alternatively, you may submit the requested list of
Settlement Class Member names, addresses, and FEINs in an electronic format, such as Excel or a tab-delimited text file. Please contact
the Claims Administrator to determine what formats are acceptable.
Provide the amount of money you spent on each drug for prescriptions filled before May 20, 2020 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.
You do not need to provide any documentation at this time. However, the Claims Administrator may ask for additional proof of purchase.
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.