INSTRUCTIONS FOR SUBMITTING YOUR THIRD‐PARTY PAYOR CLAIM FORM


A Third‐Party Payor (“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 Notice and Claims Administrator will only consider the Class Member’s Claim Form. The Notice and Claims Administrator may request supporting documentation in addition to the documentation and information requested below. The Notice and Claims Administrator may reject a claim if the TPP Class Member or their authorized agent does not provide all requested documentation 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 “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 “Section B – AUTHORIZED AGENT ONLY,” in addition to the other information requested by this Claim Form. Do not submit a Claim Form on behalf of any Class Member unless that Class Member provided prior authorization to submit the Claim Form.

If you are submitting a Claim Form only as an authorized agent of one or more Class Members, 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.

To qualify to receive a payment from the Settlement, you must complete and submit this Claim Form and you may need to provide certain requested documentation to substantiate your Claim.

Your failure to complete and submit the Claim Form by August 11, 2022, will prevent you from receiving any payment from the Settlement. Submission of this Claim Form does not ensure that you will share in the payments related to the Settlement. If the Notice and Claims Administrator rejects or reduces your Claim, you may invoke the dispute resolution process described on the subsequent pages.

CLAIM INFORMATION AND DOCUMENTATION REQUIREMENTS

Please provide the following information to support your Claim for purchases and/or reimbursement of Restasis® for use by your members, employees, insureds, participants, or beneficiaries, where such persons purchased the drug in a pharmacy or received Restasis® by mail‐order prescription, in the following states: Arizona, Arkansas*, California, Colorado, the District of Columbia, Florida, Hawaii, Illinois, Iowa, Kansas, Michigan, Minnesota, Mississippi, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Oregon, Rhode Island, South Dakota, Tennessee, Utah, West Virginia, and Wisconsin from May 1, 2015 through July 31, 2021.

* With respect to Arkansas only, Class Members must have paid for and/or provided reimbursement for Restasis® between May 1, 2015 and July 31, 2017.

  • a) Unique patient identification number or code
  • b) NDC Number (A list of NDC Numbers available on this website using the links below.) – e.g., 00000‐0000‐00
  • c) Fill Date or Date of Service – e.g., 01/01/2016
  • 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
  • g) A notation identifying claims for which, as of the date in item c) above, you were not providing prescription drug coverage, and, instead, acted in an Administrative Services Only (ASO) or Third‐Party Administrator (TPA) capacity

Information submitted will be covered by the Protective Order entered by the Court. For your convenience, an exemplar spreadsheet containing these categories can be downloaded here. Please use this format if possible. The hard copy version of the TPP Claim Form, also available for download by clicking here, provides a list of the NDCs that the Notice and Claims Administrator will consider. If possible, please provide the electronic data in Microsoft Excel, ASCII flat file pipe “|”, tab‐delimited, or fixed‐width format.

Please provide as much of the information requested above as possible. Transaction data supporting claims is mandatory for claims of $100,000 or more, although the Notice and Claims Administrator may also require transaction data for claims of less than $100,000, so keep related transaction data and any other documentation supporting your Claim (e.g., invoices) in case the Notice and Claims Administrator requests it later. If your Claim is for less than $100,000, you should still provide the transaction data with your Claim submission if you can. If, after an audit of your Claim, the Notice and Claims Administrator still has questions about your Claim and you have not provided sufficient substantiation of your Claim, the Notice and Claims Administrator may reject your Claim.

Please contact the Notice and Claims Administrator at 1‐877‐868‐6810 with any questions about the required claims information or documentation.