California Attorney General Settlement Proof of Claim
Section A: Claimant Identification
Please provide us with the following information related to the individual who PAID for Provigil, Nuvigil, and/or generic
versions of Provigil (modafinil) dispensed pursuant to a prescription for one or more of these drugs. This person is referred to
as the “Claimant.” If the person who PAID for the Provigil, Nuvigil, and/or generic versions of Provigil is different than the
person who was prescribed the drugs, then the Claimant is still the person who PAID for the drugs. So, for example, if a parent
purchased Provigil for their child, then the parent is the Claimant.
* By providing your e-mail address, you authorize the Settlement Administrator to use it in providing
you with information relevant to this claim.
Section B: Eligible Claimants
You should file this Proof of Claim Form if, during the period from June 24, 2006 through December 31, 2012, you resided in
California and purchased and/or paid for Provigil, Nuvigil, and/or generic versions of Provigil (modafinil) dispensed
pursuant to a prescription for personal consumption by you or for another under your caregiving in any state in the United States or the
District of Columbia. Your purchases of these drugs are eligible regardless of the out-of pocket-costs you paid, even if you
were partially or fully reimbursed by insurance. Employees of the defendants in
Vista Healthplan v. Cephalon and State of
California v. Cephalon
are not eligible to submit a claim. The judge and his immediate family are not eligible to submit a
Section C: Purchase Information
Below, please write down the total number of prescriptions pursuant to which you purchased and/or paid for Provigil, Nuvigil,
and/or generic versions of Provigil (modafinil) during the period from June 24, 2006 to December 31, 2012 in any state in the
United States or the District of Columbia. You must have been a California resident at the time you purchased and/or paid for
Provigil, Nuvigil, and/or modafinil.
A Claimant “paid” for Provigil, Nuvigil, or generic versions of Provigil (modafinil) if, for example, the Claimant had
insurance and paid a co-payment or a co-insurance payment (that is, the Claimant's unreimbursed out-of-pocket cost) and
insurance covered the rest. Also, an insured Claimant may have “paid” for the drug if she paid for the entire cost of the
drug because the Claimant had not met a deductible. A Claimant not covered by insurance who purchased the drug would also
be considered to have “paid” for the drug.
Section D: Releases
The Settlement Agreement between the Attorney General of the State of California and Teva Pharmaceutical Industries Ltd.
describes in detail what claims you are releasing in this case (whether or not you file a Proof of Claim, unless you have
excluded yourself). If you would like to review the Releases, they are available on the Court Documents page of this website.
Section E: Sworn Statement
By signing this Proof of Claim, I declare under penalty of perjury that: (1) all of the information provided in this
Claim Form is true and correct to the best of my knowledge; (2) the Claimant is an Eligible Claimant as described in
Section B above; (3) the Claimant purchased Provigil, Nuvigil, and/or Modafinil pursuant to the number of prescriptions
stated in Section C above) at some time during the period from June 24, 2006 through December 31, 2012; and (4) if not
submitting this for myself, I am authorized to submit this form on behalf of the Claimant identified above.
Please note that signing a Proof of Claim that contains false information could constitute perjury.