A Third-Party Payor (“TPP”) Class Member, or an authorized agent can complete this Claim Form.
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 Notice and Claims Administrator may request supporting documentation in addition to the documentation and
information requested below. The Notice and Claims Administrator may reject a claim if the Class Member or
their authorized agent does not provide all requested documentation in a timely manner.
- Claims Methodology 1 - Transactional Claims Data Available Template
- Claims Methodology 2 - Transactional Claims Data Unavailable Template
- Applicable NDC List
- Applicable ICD and HCPCS List
To file your claim online
To file your claim by mail, download a copy of the claim form below
Note: These documents are in PDF format. To view the
documents, you will need Adobe Acrobat Reader
on your computer or other internet-enabled device.
