A Third-Party Payor (“TPP”) End Payor Class member, or an authorized agent for a TPP, can complete this Claim Form. If both an End Payor Class member and its authorized agent submit a Claim Form, the Settlement Administrator will only consider the End Payor Class member’s Claim Form. The Settlement Administrator may request supporting documentation in addition to the documentation and information requested below. The Settlement Administrator may reject a claim if the End Payor Class member or their authorized agent does not provide all requested documentation in a timely manner.

If you are an End Payor Class member submitting a Claim Form on your own behalf, you must provide the information requested in "Section A – COMPANY OR HEALTH PLAN END PAYOR CLASS MEMBER ONLY,” in addition to the other information requested by this Claim Form.

If you are an authorized agent of one or more End Payor 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 End Payor Class member unless that End Payor Class member provided you with prior written authorization to submit this Claim Form. Such written authorization must accompany this Claim Form.

If you are submitting a Claim Form only as an authorized agent of one or more End Payor Class members, you may submit a separate Claim Form for each End Payor Class member, OR you may submit one Claim Form for all such End Payor Class members as long as you provide the information required for each End Payor Class member on whose behalf you are submitting this Claim Form.

If you are submitting Claim Forms both on your own behalf as an End Payor Class member AND as an authorized agent on behalf of one or more End Payor Class members, you should submit one Claim Form for yourself, completing Section A and another Claim Form or Claim Forms as an authorized agent for the other End Payor Class member(s), completing Section B.

To qualify to receive a payment from the Settlement, you must complete and submit this Claim Form either on paper or electronically on the website, www.SuboxAntitrust.com, and you may need to provide certain requested documentation to substantiate your Claim.

Your failure to complete and submit the Claim Form postmarked (if mailed) or received (if submitted online) on or before February 17, 2024, 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 Settlement Administrator rejects or reduces your Claim, you may invoke the dispute resolution process described on page 6.

CLAIM INFORMATION AND DOCUMENTATION REQUIREMENTS
Please provide the following information to support your Claim for purchases and/or reimbursement during the period between December 22, 2011 and August 21, 2023, of Co-Formulated Buprenorphine/Naloxone ("Suboxone") and its AB-rated generic equivalents in any form for consumption by its members, employees, insureds, participants, or beneficiaries, where such persons purchased the drug in a pharmacy or received the drug by mail-order prescription, in Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Oklahoma, Oregon, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming, and District of Columbia.

a) Unique patient identification number or code
b) NDC Number (a list of NDC Numbers can be downloaded from the Settlement website, www.SuboxAntitrust.com) – e.g., 00000-0000-00
c) Fill Date or Date of Service – e.g., 1/1/2012
d) Location (State) of Service – e.g., CA
e) Amount Billed (not including dispensing fee) – e.g., $123.50
f) Amount Paid by the TPP net of co-pays, deductibles, and co-insurance – e.g., $118.50
If you are submitting a Claim Form on behalf of multiple End Payor Class members, also provide the following information for each purchase or reimbursement:
g) Plan or Group Name
h) Plan or Group FEIN

For your convenience, an exemplar spreadsheet containing these categories is attached at the end of this Claim Form. In addition, an Excel spreadsheet can be downloaded from the website, www.SuboxAntitrust.com. Please use this format if possible. Following the exemplar spreadsheet, the website provides a list of the NDCs that the Settlement Administrator will consider. If possible, please provide the electronic data in Microsoft Excel, ASCII flat file pipe “|”, tab-delimited, or fixed-width format.

Transaction data supporting claims is mandatory for claims of $300,000 or more, although the Settlement Administrator may also require transaction data for claims of less than $300,000, so keep related transaction data and any other documentation supporting your Claim 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.

Please contact the Settlement Administrator at 1-877-311-3735 with any questions about the required claims information or documentation. Please do not contact the Court concerning this matter.