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.
If both a Class Member and its authorized agent submit a Proof of Claim, the Settlement Administrator will only consider the Class Member’s Proof of
Claim. 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
If you are a Class Member submitting a Proof of Claim on your own behalf, you must provide the information requested in
“Section A – COMPANY OR HEALTH PLAN CLASS MEMBER ONLY,”
in addition to the other information requested by this Proof of Claim.
If you are an authorized agent
of one or more Class Members, you must provide the information requested in “Section B – AUTHORIZED AGENT ONLY,”
addition to the other information requested by this Proof of Claim.
Do not submit a Proof of Claim on behalf of any Class Member unless that Class
Member provided prior authorization to submit the Proof of Claim.
If you are submitting a Proof of Claim only as an authorized agent of one or more Class Members, you may submit a separate Proof of Claim for each
Class Member, OR you may submit one Proof of Claim for all such Class Members as long as you provide the information required for each Class Member on
whose behalf you are submitting the form.
If you are submitting Proofs of Claim both on your own behalf as a Class Member AND as an authorized agent on behalf of one or more Class Members, you
should submit one Proof of Claim for yourself, completing Section A and another Proof of Claim or Proofs of Claim as an authorized agent for the other
Class Member(s), completing Section B.
To qualify to receive a payment from the Settlement, you must complete and submit this Proof of Claim either on paper or electronically on the
Settlement website, www.RanbaxyTPPLitigation.com, and you may need to provide certain requested documentation to substantiate your Claim.
Your failure to complete and submit the Proof of Claim postmarked (if mailed) or received (if submitted online) on or before October 11, 2022
prevent you from receiving any payment from the Settlement. Submission of this Proof of Claim does not ensure that you will share in the payments
related to the Settlement. If the Settlement Administrator rejects or reduces your Claim, you may invoke the dispute resolution process described
on pages 5-6.
CLAIM INFORMATION AND DOCUMENTATION REQUIREMENTS
Please provide the following information to support your Claim for purchases and/or reimbursement AB-Rated generic Nexium, brand and/or AB-rated
generic Diovan, and brand and/or AB-rated generic Valcyte for use by your members, employees, insureds, participants, or beneficiaries, where such
persons purchased the drug in a pharmacy or received the drug by mail-order prescription, in the United States or its territories.
a) Unique patient identification number or code
b) NDC Number (a list of NDC Numbers can be downloaded from the Settlement website, www.RanbaxyTPPLitigation.com
) – e.g., 00000-0000-00
c) Fill Date or Date of Service – e.g., 01/01/2018
d) Location (State) of Service – e.g., CA
e) Amount Billed (not including dispensing fee) – e.g., $123.50
f) Amount Paid by the TPP net of co-pays, deductibles, and co-insurance – e.g., $118.50
If you are submitting a Proof of Claim on behalf of multiple Class Members, also provide the following information for each purchase or reimbursement:
g) Plan or Group Name
h) Plan or Group FEIN
Information submitted will be covered by the Protective Order entered by the Court. For your convenience, an Excel spreadsheet can be downloaded from
the Settlement website, www.RanbaxyTPPLitigation.com
. Please use this format if possible. Following the exemplar spreadsheet, the website provides a
list of the NDCs that the Settlement Administrator will consider. If possible, please provide the electronic data in Microsoft Excel, ASCII flat file
pipe “|”, tab-delimited, or fixed-width format.
Transaction data supporting claims is mandatory for claims of $300,000 or more per drug, although the Settlement Administrator may also require
transaction data for claims of less than $300,000 per drug, so keep related transaction data and any other documentation supporting your Claim in case
the Settlement Administrator requests it later. If your Claim is for less than $300,000, you should still provide the transaction data with your
Claim submission if you can. If, after an audit of your Claim, the Settlement Administrator still has questions about your Claim and you have not
provided sufficient substantiation of your Claim, the Settlement Administrator may reject your Claim.
Please contact the Settlement Administrator at 1-877-888-9232 with any questions about the required claims information or documentation.