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Bmsawpsettlement.com

OFFICIAL USE ONLY
MUST BE POSTMARKED
NO LATER THAN
NOVEMBER 19, 2010
In re: Pharmaceutical Industry Average Wholesale Price Litigation Docket No. 01-CV-12257 PBS, MDL No. 1456 To get a share of the Settlement Fund, you need to complete and sign this Claim Form and submit it to: This Claim Form must be received or postmarked no later than November 19, 2010.
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 Claims Administrator at 1-877-690-7097.
A TPP Settlement Class Member (“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 Claims Administrator will only consider the Class Member’s Claim Form. The Claims Administrator may request supporting documentation. The claim may be rejected if any requested documentation is not provided. If one or more Class Members has authorized you to submit a Claim Form on its behalf, you must provide the
information requested in Section B in addition to the other information requested by this Claim Form. You may submit a
separate Claim Form for each Class Member that has duly authorized you to do so, OR you may submit one Claim Form
for all such Class Members that have authorized you to do so. If you are submitting Claim Forms both on your own
behalf as a Class Member AND on behalf of one or more Class Members that have authorized you to do so, you should
submit one Claim Form for yourself and another Claim Form for the other Class Member(s). Do not submit a Claim Form
on behalf of any Class Member without specific prior authorization from that Class Member.

SECTION A – CLAIMANT IDENTIFICATION
Please indicate whether you are claiming on your own behalf as a Class Member or as the authorized agent of
one or
more Class Members by placing an “X” in the appropriate space below. If you wish to make a claim as a
Class Member and also as the authorized agent of other Class Members, please complete one Claim Form for
your claim as a Class Member and a separate Claim Form for those Class Members for whom you are authorized
to submit a claim:
† I am filing as the Authorized Agent of a Class Member** ** As Authorized Agent, please check how your relationship with the Class Member is † Third Party Administrator (other than a Pharmacy Benefits Manager) † Pharmacy Benefits Manager † Other (Explain): __________________________________________ SECTION B – CLASS MEMBER OR AGENT INFORMATION
Class Member’s/Authorized Agent’s Name Class Member’s/Authorized Agent’s Tax Identification Number If you file as a Class Member, list other names by which you have been known or other Federal Employer Identification Numbers (“FEINs”) you have used from January 1, 1991 through December 31, 2004. If you are filing as the Class Member, check the term below that best describes your company/entity: F Health Insurance Company/HMO F Self-Insured Employee Health Plan F Self-Insured Union Health & Welfare Fund F Other (Explain): SECTION C – CLAIM BY AUTHORIZED AGENT
Please list the name and FEIN of every Class Member 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 Class Member names and FEINs in an acceptable electronic format. Please contact the Claims Administrator to determine what formats are acceptable. SECTION D – TOTAL AMOUNT OF BMS DRUG PURCHASES
For the Class Member on whose behalf you are submitting a claim, state the total and final amount paid or
reimbursed, net of rebates, chargebacks, co-pays, and/or co-insurance for each BMS Drug set out in the chart below
with a date of service or date of fill from January 1, 2003 to December 31, 2003. If you are claiming more than
$300,000, you will need to provide additional information (See Section F):
Drug Name
MediGap TPP Class
Private Payor TPP Class
Blenoxane
Etopophos
Paraplatin
Claimant certifies that the figures are true and accurate and are based upon actual records maintained by or otherwise available to the claimant. SECTION E – JURISDICTION OF THE COURT AND CERTIFICATION
By signing below, I hereby swear and affirm that: (1) I have authority to submit this Claim Form either directly or on behalf
of the Class Member or as its Authorized Agent, and, in turn, have been given the authority to submit this Claim Form
by each Class Member identified in this Claim Form and in any attachments to it, and to receive on behalf of each such
Class Member any and all amounts that may be allocated from the TPP Settlement Pool to such Class Member; (2) the
information contained in this Claim Form and any attachments hereto is true and accurate, based on records maintained
by or otherwise available to me; (3) I, the Authorized Agent (if any), and the Class Member on whose behalf this Claim
Form is submitted, hereby submit to the jurisdiction of the United States District Court for the District of Massachusetts
(the “Court”) for all purposes associated with this Claim Form and the Settlement, including resolution of disputes
relating to this Claim Form; (4) in the event that amounts from the TPP Settlement Pool are distributed to the Authorized
Agent of a Class Member, and the Class Member later claims that the Authorized Agent did not have the authority to
claim and receive such amounts on its behalf, the Authorized Agent, I, and/or my employer will hold the Class, Counsel
for the Class, Defendants, Counsel for Defendants, and the Claims Administrator harmless with respect to any claims
made by said Class Member.
The following additional information is to be provided by the Individual that signs and certifies this Claim Form: I am filing this Claim Form as the authorized employee of the following Class Member or Authorized Agent for a Class Member: Mail the completed Claim Form to the address listed on page 1, postmarked no later than NOVEMBER 19, 2010.
SECTION F – CLAIM DOCUMENTATION INSTRUCTIONS
If you are claiming less than $300,000 of total purchases of all BMS Drugs for the 2003 period, you do not need to attach any additional information. However, even if your purchase amount is less than $300,000, you should retain the information required for claims over $300,000 because any claim may be audited. If you are claiming $300,000 or more of total purchases of all BMS Drugs you must provide documentation with your
Claim Form to have your claim considered by the Claims Administrator. Please provide the required data fields necessary
for your participation as a TPP Class Member as presented in the Data Field Layout sample on page 5, for all paid claims
with a date of service or date of fill between January 1, 2003 to December 31, 2003 net of co-pay deductibles or co-
insurance. Please provide this data along with the Claim Form to the Claims Administrator received or postmarked no
later than November 19, 2010:
J-Code or NDC Number – provide the applicable J-Code or NDC Number for each transaction. A list of the J-Codes and NDC Numbers are annexed as Attachment A. Patient Identifier – provide a random encrypted patient identification number. This number must consistently reflect the same patient. Service and/or Fill Date – we expect service date will be available for J-Code entries and fill date will be available for NDC entries. Please include both if they are available. Group Number – provide the group number assigned to each transaction. As part of the auditing process, you may be asked to provide the corresponding group name for each group number. Only the Claims Administrator will have access to this information. Amount Billed – billed charges or the initial amount billed by the provider or providers before any adjustments. Net Amount Paid – final amount paid for each discrete transaction, net of co-pays, deductibles, co-insurance, and any other credits and adjustments after initial payment. OTHER INFORMATION
If you are able, please provide units for each transaction. Please provide the electronic data in either Mircosoft Excel format or ASCII flat file pipe delimited “I” or fixed-width format. Refer to the sample layout below.
Finally, please provide a list of all self-funded healthcare plans (“SFPs”) for which you are authorized to make All information you provide is subject to the protective order governing this action. Data Field Layout for Claims of $300,000 or More
Service/Fill
Net Amount
or J-Code
Identifier
COLUMN TOTALS
TOTAL CLAIM
DESCRIPTION
ATTACHMENT A - LIST OF J-CODES AND NDC NUMBERS
DESCRIPTION
DESCRIPTION

Source: http://www.bmsawpsettlement.com/pdfs/TPPClaimForm.pdf

231(pag)

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