Third Party Claim Form


Part I: Claimant Identification



PART II – CLAIM FOR PROVIGIL OR GENERIC PROVIGIL (MODAFINIL)

Please type in the box below the total amount paid or reimbursed for Provigil or generic Provigil (modafinil) net of co‐pays, deductibles, and co‐insurance 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, other than for resale, from June 1, 2006 through August 8, 2019. You may not include amounts for which you have been reimbursed by another entity. For mail order purchases, the state of residence of the patient is deemed to be the state in which the purchase occurred.


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You must submit claims data and information in support of the purchase amounts stated above if your total claim amount is more than $300,000 (see Part III). If your total claim is $300,000 or less, you need not provide complete claims data with this Claim Form, but the Settlement Administrator may require supporting documentation.


PART III – CLAIM DOCUMENTATION INSTRUCTIONS

If your total claim amount is more than $300,000, you must provide documentation with your Claim Form sufficient to show the amount of purchases of Provigil or generic Provigil (modafinil) during the relevant period. Please provide the required data fields as presented in the table below.


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

A HIPPA QUALIFIED PROTECTIVE ORDER HAS BEEN ENTERED TO PROTECT THE CONFIDENTIALITY OF ANY INFORMATION THAT YOU SEND TO THE SETTLEMENT ADMINISTRATOR AND TO LIMIT ITS USE TO ONLY THIS CLAIM PROCESS.

PART IV – PURCHASE INFORMATION REGARDING PERIOD FROM 6/1/06 TO 9/30/13

In addition to the information you provide above, please also type or print in the box below the total amount paid or reimbursed for Provigil® or generic Provigil® (modafinil) net of co‐pays, deductibles, and co‐insurance 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, other than for resale, from June 1, 2006 through September 30, 2013. You may not include amounts for which you have been reimbursed by another entity. For mail order purchases, the state of residence of the patient is deemed to be the state in which the purchase occurred.


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PART IV – CERTIFICATION AND JURISDICTION OF THE COURT

I have read and am familiar with the contents of the Instructions accompanying this Claim Form. I certify that the information I have set forth in this Claim Form and in any documents attached by me are true, correct and complete to the best of my knowledge. I certify that the Class Member(s) I represent paid the total amount set forth above in out‐of‐pocket expenditures for purchases or reimbursements of brand or generic Provigil® prescriptions and that the Class Member(s) were at risk for this amount. In addition, I certify that the Class Members I represent are neither: (i) governmental entities (other than a government funded employee benefit plan); nor (ii) fully insured health plans (i.e., plans that purchase insurance from another third-party payor covering 100% of the plan’s reimbursement obligations to its members).

To the extent I have been given authority to submit this Claim Form by a Class Member(s) on its behalf, and accordingly am submitting this Claim Form in the capacity of an Authorized Agent with authority to submit it by the Class Member(s) identified, I have been authorized to receive payment on behalf of the Class Member(s). In the event amounts from the Settlement Fund are distributed to me, and a Class Member(s) later contends that I did not have authority to claim and/or receive such amounts on its behalf, I agree to hold the Class, Class Counsel, and the Settlement Administrator harmless with respect to any claims made by the Class Member(s).

I hereby submit to the jurisdiction of the United States District Court for the Eastern District of Pennsylvania for all purposes connected with the Claim Form, including resolution of disputes relating to this Claim Form. I acknowledge that any false information or representations contained herein may subject me to sanctions, including the possibility of criminal prosecution. I agree to supplement this Claim Form by furnishing documentary backup for the information provided herein upon request of the Settlement Administrator.


I certify that the above information supplied by the undersigned is true and correct to the best of my knowledge.



PART V – 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 at www.ProvigilSettlement.com.