In re Ranbaxy Marketing, Sales Practices and Antitrust Litigation

SECTION A: Company or Health Plan Class Member Only

SECTION B: Authorized Agent Only

Section A: Company or Health Plan Class Member Only

Company or Health Plan Name: *

Contact Name:

Care of (if applicable):

Street Address: *

City: *

State: *

Zip: *

Area Code - Telephone Number: *

Tax Identification Number: *

Email Address: *

List other names by which your company or health plan has been known or other Federal Employer Identification Numbers ("FEINs") it has used since September 28, 2012:

Other Name:

Other FEIN:

Click Add Other Name/FEIN to add to submission.

Other Name

Other FEIN

Action

Health Types: *

Section B: Authorized Agent Only

As an Authorized Agent, please check how your relationship with the Settlement Class Member(s) is best described:

Relationship Types: *

Authorized Agent's Company Name: *

Contact Name:

Address 1: *

City: *

State: *

Zip: *

Area Code - Telephone Number: *

Authorized Agent's Tax Identification Number: *

Email Address: *

Please list the name and FEIN of every Settlement Class Member (i.e., Company or Health Plan) for whom you have been duly authorized to submit this Claim Form (attach additional sheets to this Claim Form as necessary). Alternatively, you may submit the requested list of Settlement Class Member names and FEINs in an electronic format, such as Excel or a tabdelimited text file saved on a disk or flash drive. Please contact the Claims Administrator to determine what formats are acceptable.

Class Member Name:

Class Member Fein:

Click Add Class Member to add to submission.

Class Member's Name

Class Member's FEIN

Action

Section C: Purchase Information

Please enter the total amount paid or reimbursed for AB-Rated generic Nexium, brand and/or AB-rated generic Diovan, and brand and/or AB-rated generic Valcyte net of co-pays, deductibles, and co-insurance for use by your members, employees, insureds, participants, or beneficiaries, where such persons purchased the drug in a pharmacy or received the drug by mail-order prescription in the United States and its territories during the applicable time periods.

Please note that certain groups have been excluded from the Classes in this case. Do not submit a Proof of Claim for or on behalf of any of the following excluded groups:

(a) natural person consumers;
(b) Defendants Sun Pharmaceutical Industries Limited and Ranbaxy Inc., their officers, directors, management, employees, subsidiaries, and affiliates;
(c) federal and state governmental entities, except for cities, towns, municipalities, or counties with self-funded prescription drug plans;
(d) entities who purchased Diovan, Nexium, Valcyte, or their AB-rated generic versions for purposes of resale;
(e) fully insured health plans (i.e., health plans that purchased insurance covering 100% of their reimbursement obligation to members);
(f) pharmacy benefit managers; or
(g) any entity that previously submitted a valid exclusion request from one or more of the Classes.

TOTAL AMOUNT YOU PAID OR REIMBURSED FOR BRAND AND/OR AB-RATED GENERIC DIOVAN NET OF CO-PAYS, DEDUCTIBLES, AND CO-INSURANCE FROM SEPTEMBER 28, 2012 THROUGH APRIL 1, 2020:

TOTAL AMOUNT YOU PAID OR REIMBURSED FOR BRAND AND/OR AB-RATED GENERIC VALCYTE NET OF CO-PAYS, DEDUCTIBLES, AND CO-INSURANCE FROM AUGUST 1, 2014 THROUGH APRIL 1, 2020:

TOTAL AMOUNT YOU PAID OR REIMBURSED FOR ONLY AB-RATED GENERIC NEXIUM NET OF CO-PAYS, DEDUCTIBLES, AND CO-INSURANCE FROM MAY 27, 2014 THROUGH FEBRUARY 1, 2019:

Section D: Proof of Payment and Disputes Regarding Claim Amounts

Please provide as much of the information requested above as possible. Transaction data supporting claims is mandatory for claims of $300,000 or more per drug, although the Settlement Administrator may also require transaction data for claims of less than $300,000 per drug, so keep related transaction data and any other Claim Documentation supporting your Claim (e.g., invoices) in case the Settlement Administrator requests it later. If your Claim is for less than $300,000, you should still provide the transaction data with your Claim submission if you can. If, after an audit of your Claim, the Settlement Administrator still has questions about your Claim and you have not provided sufficient substantiation of your Claim, the Settlement Administrator may reject your Claim.

If the Settlement Administrator rejects or reduces your claim and you believe the rejection or reduction is in error, you may contact the Settlement Administrator to request further review. If the dispute concerning your claim cannot be resolved by the Settlement Administrator and Lead Class Counsel, you may request that the Court review your claim.

To request Court review, you must send the Settlement Administrator a signed written statement that (a) states your reasons for contesting the rejection or payment determination regarding your claim; and (b) specifically states that you “request that the Court review the determination regarding this claim.” You must include all Claim Documentation supporting your argument(s). The Settlement Administrator and Lead Class Counsel will present the dispute to the Court for review, which may include public filing with the Court of your claim and the supporting documentation. Please note: Court review should only be sought if you disagree with the Settlement Administrator’s determination regarding your claim

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

Select files

Files To Be Uploaded	Size	Action

Section E: Certification

I/We have read and am/are familiar with the contents of the Instructions accompanying this Proof of Claim. I/We certify that the information I/we have set forth in the above Proof of Claim and in any documents attached by me/us are true, correct, and complete to the best of my/our knowledge. I/We certify that I/we, or the Class Member(s) I/we represent:

a) paid or reimbursed for brand and/or generic Diovan and Valcyte, and generic Nexium in the total amount set forth above for use by members, employees, insureds, participants, or beneficiaries, where such persons purchased the drug in a pharmacy or received the drug by mail-order prescription, in the United States and its territories in the applicable time periods;
b) did not seek to be excluded (“opt out”) from one or more of the Classes in this Action;
c) did not pay for or provide reimbursement of brand and/or generic Diovan and Valcyte, and generic Nexium for purposes of resale;
d) has/have not served as officer, director, management, employee of the Defendants, or their subsidiaries or affiliates; and
e) is/are not a federal and state governmental entities (except that cities, towns, municipalities or counties with self-funded prescription drug plans may submit Proofs of Claims).

I/We further certify I/we have provided all of the information requested above to the extent I/we have it.

To the extent I/we have been given authority to submit this Proof of Claim by one or more Class Members on their behalf, and accordingly am/are submitting this Proof of Claim in the capacity of an authorized agent with authority to submit it, and to the extent I/we have been authorized to receive on behalf of the Class Member(s) any and all amounts that may be allocated to them from the Settlement Fund, I/we certify that such authority has been properly vested in me and that I/we will fulfill all duties I/we may owe the Class Member(s). If amounts from the Net Settlement Fund are distributed to me/us and a Class Member later claims that I/we did not have the authority to claim and/or receive such amounts on its behalf, I/we and/or my/our employer will hold the Class, Lead Class Counsel, and the Settlement Administrator harmless with respect to any claims made by the Class Member.

I/We hereby submit to the jurisdiction of the United States District Court for the District of Massachusetts for all purposes connected with this Proof of Claim, including resolution of disputes relating to this Proof of Claim. I/We acknowledge that any false information or representations contained herein may subject me to sanctions, including the possibility of criminal prosecution. I/We agree to supplement this Proof of Claim 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

Claimant Signature: *

Position/Title: *

Reminder Checklist:

1. Please complete and sign the above Claim Form. Attach or upload any documentation supporting your claim.

2. Keep a copy of your Claim Form and supporting documentation for your records.

3. If you move and/or your name changes, please send your new address and/or your new name or contact information to the Settlement Administrator at info@RanbaxyTPPLitigation.com or via U.S. Mail at the address listed above.