INSTRUCTIONS FOR SUBMITTING YOUR THIRD-PARTY PAYOR CLAIM FORM


The information you provide will be kept confidential and will be used only for administering this Settlement. If you have any questions, please call the Settlement Administrator at 1‐877‐324‐0380

If you are a Class Member submitting a claim on your own behalf, you must provide the information requested in “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 “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 “COMPANY OR HEALTH PLAN CLASS MEMBER ONLY” and another Claim Form or Forms as an authorized agent for the other Class Member(s), completing “AUTHORIZED AGENT ONLY.” Do not submit a claim on behalf of any Class Member unless that Class Member provided you prior authorization to submit the claim on their behalf.

In order to qualify to receive a payment from this Settlement, you must complete and submit this Proof of 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 information online and upload the requested data by September 21, 2020, will prevent you from receiving any payment from this Settlement. Submission of this Proof of Claim form does not ensure that you will share in the payments related to the Settlement. If the Settlement Administrator disputes a material fact concerning your Claim, you will have the right to present information in a dispute resolution process. For more information on this process, visit www.InReLoestrin24FeAntitrustLitigation.com.

CLAIM DOCUMENTATION REQUIREMENTS

You must provide all the information requested in “Purchase Information.” You must submit claims data and information in support of the purchase amounts stated above if your total net claim amount is more than $300,000. Your claimed purchase amounts of Loestrin 24 Fe, Minastrin 24 Fe and/or their AB‐rated generic equivalents must be net of co‐ pays, deductibles, and co‐insurance.

It is mandatory that you provide the data for all categories listed below. Affidavits that do 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 Proof of 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.

For your convenience, an exemplar spreadsheet containing these categories is available on this website. Please use this format if possible. A list of the NDCs that will be considered by the Settlement Administrator is also provided.

If possible, please provide the electronic data in either Microsoft Excel format of ASCII flat file pipe “|” or tab‐delimited or fixed‐width format.

Please contact the Settlement Administrator at 1‐877‐324‐0380 with any questions about the required claims data.