Claim Form

An End-Payor Class Member, also known as a Third-Party Payor (“TPP”) Class Member, or an authorized agent can complete this Proof of Claim. Individual consumers are not part of this lawsuit.

TPPs are entities (besides the patient) that provide payment or reimbursement for health care expenses, like prescription drug benefits. They include entities such as health insurance companies, self-insured health and welfare plans that make payments from their own funds, and other health benefit providers and entities with self-funded plans that contract with a health insurer or administrator to administer their prescription drug benefits. Third-Party Payors include such private entities that may provide prescription drug benefits for current or former public employees and/or public benefits programs, but only to the extent that such a private entity purchased for consumption by its members, employees, insureds, participants, or beneficiaries.

The Settlement Administrator may request supporting documentation in addition to the documentation and information requested below. The Settlement Administrator may reject a claim if the Class Member or their authorized agent does not provide all requested documentation in a timely manner.

To file your claim by mail, download a copy of the claim form below

Note: These documents are in PDF format. To view the
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