SECTION I – Class Action Proof of Claim


Section A: Claimant Identification

Please provide us with the following information related to the individual who PAID for Provigil or generic versions of Provigil (Modafinil). This person is referred to as the “Claimant.” If the person who PAID for the Provigil 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: Class Definition

You should file this Claim Form if you purchased Provigil or generic versions of Provigil (modafinil) intended for consumption by you or your family in Alabama, Arizona, California, District of Columbia, Florida, Hawaii, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Nebraska, Nevada, New Mexico, New York, North Carolina, North Dakota, South Dakota, Tennessee, Utah, Vermont, West Virginia and Wisconsin during the period from June 24, 2006 through August 8, 2019. “Purchased” in this case means you paid for some or all of the purchase price of the cost of the drug. (For example, “purchased” includes making a co-payment).



Section C: Exclusions

The following individual are excluded from the Class, and therefore may not participate in the Settlements:
Employees of Defendants;
Insured individuals covered by plans imposing a flat dollar co-pay that was the same dollar amount for generic as for brand drug purchases; and
Insured individuals who purchased only generic modafinil pursuant to a fixed co-pay applicable to generic drugs.



Section D: Purchase Information

Below, please write down the Total Amount Paid for Provigil or generic versions of Provigil (Modafinil) from June 24, 2006 through August 8, 2019 for prescriptions filled in the following States: Alabama, Arizona, California, District of Columbia, Florida, Hawaii, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Nebraska, Nevada, New Mexico, New York, North Carolina, North Dakota, South Dakota, Tennessee, Utah, Vermont, West Virginia and Wisconsin. (For mail order purchases, the state of residence of the patient is deemed to be state in which the purchase occurred.)

A Claimant “paid” for Provigil 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.


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Section E: Required Proof of Payment

Please provide proof of at least one purchase of Provigil or modafinil.

Examples of acceptable proofs of payment include, but are not limited to:
• Records from your pharmacy showing that you paid for Provigil or modafinil;
• An EOB (explanation of benefit) from your insurer that shows you paid for Provigil or modafinil; or
• A letter from your Doctor stating that you were prescribed Provigil or modafinil during the relevant time period.
If you are having difficulty obtaining appropriate proof of payment, please contact the Settlement Administrator for assistance.

Even if you cannot locate proof of one purchase, you should still submit this Proof of Claim form if you believe you are a Class Member because the Settlement Administrator may be able to help you find proof of payment.

NOTE: The Settlement Administrator may ask for additional proof of payment after you submit your Proof of Claim Form, so please keep all records of your purchases.

Please use the browse option, by clicking on “Select Files” in the box below to upload your supporting documentation.




Files To Be Uploaded Size Action

Section F: Releases

The Cephalon, Mylan and Ranbaxy Settlement Agreements describe in detail what claims you are releasing in this case whether or not you file a Claim Form, 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 G: Sworn Statement

By signing this Claim Form, 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 falls within the definition of the Class listed in Section B above; (3) the Claimant paid the amounts as indicated in this Claim Form for Provigil or generic versions of Provigil (modafinil) for the Claimant’s own use (or for the Claimant’s family or household) at some time during the period from June 24, 2006 through August 8, 2019 (4) the Claimant does not fall within any of the exclusions listed in Section C above; and (5) if not submitting this for myself, I am authorized to submit this Claim Form on behalf of the Claimant identified above.

Please note that signing a Claim Form that contains false information could constitute perjury.