INSTRUCTIONS FOR SUBMITTING YOUR THIRD-PARTY PAYOR CLAIM FORM



The information you provide will be kept confidential under a Protective Order and will be used only for administering these Settlements.

A TPP Class Member or an authorized agent can complete this Claim Form. If both a Class Member and its authorized agent submit a Claim Form, the Settlement Administrator will only consider the Class Member’s Claim Form. The Settlement Administrator may request supporting documentation. The claim may be rejected if any requested documentation is not provided in a timely manner.

If you are a Class Member submitting a Claim Form on your own behalf, you must provide the information requested in “Part 1, Section A – COMPANY OR HEALTH PLAN CLASS MEMBER ONLY,” in addition to the other information requested by this Claim Form. If you are an Authorized Agent of one or more Class Members, you must provide the information requested in “Part 1, Section B – AUTHORIZED AGENT ONLY,” in addition to the other information requested by this Claim Form.

You may submit a separate Claim Form for each Class Member, OR you may submit one Claim Form 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 Claim Forms 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 Claim Form for yourself, completing Section A and another Claim Form or Forms as an authorized agent for the other Class Member(s), completing Section B. Do not submit a Claim Form on behalf of any Class Member unless that Class Member provided prior authorization to submit the Claim Form.

In order to qualify to receive a payment from the Settlements, you must complete and submit a Claim Form either on paper or electronically on the Settlement Website, and you may need to provide certain requested documentation to substantiate your Claim.

Your failure to complete and submit the Claim Form so that is received by the Settlement Administrator by January 15, 2020, will prevent you from receiving any payment from the Settlements. Submission of a Claim Form does not ensure that you will share in the payments related to the Settlements.



IMPORTANT NOTICE FOR “SETTLING HEATH PLANS”


IF YOU ARE A THIRD-PARTY PAYOR WHO INDEPENDENTLY ENTERED INTO A SEPARATE SETTLEMENT AGREEMENT WITH THE CEPHALON DEFENDANTS (KNOWN AS THE “SETTLING HEALTH PLANS” OR “SHPs”), YOU MUST STILL FILE A CLAIM FORM IF YOU WANT TO RECOVER FROM THE MYLAN AND RANBAXY SETTLEMENTS.


CLAIM DOCUMENTATION REQUIREMENTS


You must provide the TOTAL AMOUNT PAID requested in Part II of the Claim Form. Your TOTAL AMOUNT PAID for Provigil®or generic Provigil® (modafinil) must be net of co-pays, deductibles, and co-insurance. Also, if your TOTAL AMOUNT PAID is more than $300,000, you must submit claims data and information in support of your TOTAL AMOUNT PAID.Specifically, it is mandatory that you provide the data for all categories listed below. Documentation that does not include the information listed below will not be accepted:

a) Unique patient identification number or code.
b) NDC Number (a list of NDC Numbers is included with this Proof of Claim form) – e.g., 00000-0000-00
c) Fill Date or Date of Service – e.g., 01/01/2007
d) Location (State) of Service – e.g., CA
e) Amount Billed (not including dispensing fee) – e.g., $40.00
f) Amount Paid by TPP net of co-pays, deductibles, and co-insurance – e.g., $20.00


If you are submitting a Claim Form on behalf of multiple Class Members, also provide the following information for each prescription:

g) Plan or Group Name.
h) Plan or Group FEIN – provide group number for each transaction.


If possible, please provide the electronic data in either Microsoft Excel format or ASCII flat file pipe “|” or tab-delimited or fixed-width format. For your convenience, an exemplar Excel spreadsheet, containing the categories above, can be downloaded from the Settlement Website, www.ProvigilSettlement.com. Please use this format if possible. A list of the NDCs that will be considered by the Settlement Administrator is also provided at the Settlement Website.

Please contact the Settlement Administrator at 1-877-241-7503 or info@ProvigilSettlement.com with any questions regarding the filing of your Claim Form.