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 requested below. The claim may be rejected if any
requested documentation is not provided 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 “Part 1, 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 “Part 1, Section B – 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 Section A
and another Claim Form or Forms as an authorized agent for the other Class Member(s), completing Section B.
Do not submit a Claim Form on behalf of any Class Member unless that Class Member provided prior
authorization to submit the Claim Form.
In order to qualify to receive a payment from the Settlements, you must complete and submit this 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 Form postmarked or filed online by July 3, 2020, will prevent you from receiving any payment from the Settlements. Submission of this Claim Form does not ensure that
you will share in the payments related to the Settlements. If the Notice and Claims 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.dvtmedslawsuit.com.
CLAIM DOCUMENTATION REQUIREMENTS
Please provide the below information to support your claim for Lovenox® or generic enoxaparin dispensed at pharmacies that the Class Member purchased, paid for or reimbursed for in
Arizona, Arkansas, California,
District of Columbia, Florida, Hawaii, Illinois, Iowa, Kansas, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Carolina, North Dakota,
Oregon, South Dakota, Tennessee, Utah, Vermont, West Virginia, and Wisconsin,
from September 21, 2011 through September 30, 2015.
a) Unique patient identification number or code.
b) NDC Number (a list of NDC Numbers is included with this 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
Information submitted will be covered by the Protective Order entered by the Court. 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 Claim Form page of this website. Please use this format if possible. A list of the NDCs that will be considered by the Notice and Claims Settlement Administrator
is provided on the Claim Form page of this website.
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 requested information as possible. The requested information is by default mandatory for claims of $300,000 or more, although the Notice and Claims Administrator may also require
documentation for claims of less than $300,000. For claims of less than $300,000, you should still provide the information if you can, even if not specifically requested by the Notice and Claims Administrator.
Claims that do not have any documentary substantiation at all may be rejected.
Do not include in your claim any payments or reimbursements to hospitals or similar healthcare providers. For TPPs, the settlement only includes purchases at pharmacies.
Please contact the Notice and Claims Administrator at 1-888-208-9630 or firstname.lastname@example.org with any questions about the required claims data.