Download SBACFIRST - Adderall XR® Settlement

Barba v. Shire U.S., Inc. Settlement Administrator
P.O. Box 40007
College Station, TX, 77842-4007
Must Be Postmarked
No Later Than
October 7, 2016
SBA
ADDERALL XR® SETTLEMENT
CLAIM FORM
Barba v. Shire U.S., Inc.
Case No. 13-CV-21158-LENARD/GOODMAN (S.D. Fl.)
If you wish to make a claim to receive monetary compensation as described in the Settlement Agreement, you must submit this Claim
Form to the Class Action Settlement Administrator, either by completing and submitting it online at www.AdderallXRSettlement.com,
by printing and emailing the completed Claim Form to [email protected], or by mailing the completed Claim Form
to: Settlement Administrator, PO Box 40007, College Station, TX 77842-4007. The Claim Form must be completed, verified and
submitted online OR completed, signed, and postmarked on or before October 7, 2016. Your claim is subject to review by the
Settlement Administrator and you may be contacted by the Settlement Administrator for additional information.
To qualify for monetary compensation, you must have purchased and paid some money (i.e., paid to fill a prescription) for branded
Adderall XR® from January 1, 2007 through April 11, 2016, for personal or household use (including use by a dependent or family
member) in the following states (collectively, the “Territory”):
The District of Columbia
Alabama
Arizona
California
Delaware
Florida
Georgia
Idaho
Illinois
Iowa
Kansas
Maine
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Utah
Vermont
West Virginia
Wisconsin
A complete definition of the class qualifications and exclusions is provided in the Settlement Agreement, which is available at
www.AdderallXRSettlement.com. Only claims for Adderall XR® will be paid. If you purchased and paid some money for a
generic form of or equivalent to Adderall XR® or any form of immediate release Adderall®, those purchases do not qualify
for any monetary compensation.
Purchases of Adderall XR® for yourself or your dependent or family member are included. Other purchases, such as for resale or
for commercial purposes (e.g., as a third party payor) are excluded. Your purchases are also excluded if you purchased using an
insurance plan under which you paid the same co-pay amount for branded drugs that you would pay for a generic version of that
branded drug (e.g., a flat co-pay plan).
You are also excluded from relief if you are an officer, director, legal representative, or employee of Shire.
There is a limit of one Claim Form per person (on which you may claim multiple paid prescriptions). Separate Claim Forms must
be completed for or on behalf of each member of your family or household who wishes to make a claim. The total monetary amount
you receive will depend upon the number of valid claims made by all class members, up to a maximum of $16 per qualifying
branded Adderall XR® prescription you filled. For example, if you filled 5 qualifying prescriptions, you would be entitled to up to
$80 (5 x $16=$80). A qualifying prescription is one in which Adderall XR® was purchased under the terms and conditions set forth
in this Notice and the Settlement Agreement. Claim Forms must be submitted online at www.AdderallXRSettlement.com, emailed
to [email protected] or mailed to: Settlement Administrator, PO Box 40007, College Station, TX 77842-4007.
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FOR CLAIMS
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Please provide the following required information:
Claimant Information
Fill in this circle to confirm your prescription drug coverage, if any, required a higher co-pay for a branded drug than a
generic drug
Fill in this circle if you are a parent or guardian of the branded Adderall XR® patient for whom you paid for prescriptions
Patient Name (If Different from Purchaser Name (First, MI, Last))
Purchaser Name (First, MI, Last)
Purchaser Current Street Address
Continuation of Purchaser Current Street Address
City
State
Zip Code
No Email Address (Check here if you do not have an email address)
Purchaser Email Address (optional) (If provided, your email address will only be used by the Claim Administrator to confirm your successful
submission of the claim form and claims processing purposes.)
Area code Telephone number (home)
—
Area code
—
Telephone number (work)
—
—
Qualification Information
Please complete the below:
How many Adderall XR® prescriptions did you fill between 1/1/07 and 3/31/09: (e.g., if you filled 4 prescriptions during this period, write “4”; you will then be eligible to receive up to $64 (4 x $16=$64) total for
this time period).
How many Adderall XR® prescriptions did you fill between 4/1/09 and 4/11/16: (e.g., if you filled 6 prescriptions during this period, write “6”; you will then be eligible to receive up to $96 (6 x $16=$96) total for
this time period).
Note: The amount paid per prescription filled before 3/31/09 may differ from the amount paid per prescription after 4/1/09 depending
on the number of claims and prescriptions submitted for each period.
State the name of your health insurance carrier(s) that covered part of any Adderall XR® prescription you filled, if any:
Health Insurance Carrier 1
Health Insurance Carrier 2
Health Insurance Carrier 3
Health Insurance Carrier 4
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(if none, write “N/A” or “none”; if you do not recall, write “do not recall” or list as many as you can remember)
Identify each pharmacy at which you filled a prescription for Adderall XR® between 1/1/07 and 4/11/16
Pharmacy Name
CityState
Pharmacy Name
CityState
Pharmacy Name
CityState
Pharmacy Name
CityState
CERTIFICATION
Please read, date, and sign or verify the statement below. This is required for all claims.
I hereby certify under the penalty of perjury that the information provided on this Claim Form is true and correct and that I paid money
for branded Adderall XR® in the Territory between January 1, 2007 and April 11, 2016 for each of the Adderall XR® prescriptions
for which I am here seeking reimbursement. I understand my claim is subject to review by the Settlement Administrator and I may
be contacted by the Settlement Administrator if there are questions about my claim or additional information is needed to verify my
claim. I also understand that my claim will be denied if the information I have submitted is false or inaccurate.
Signature: Dated: SUBMIT OR POSTMARK THIS CLAIM FORM ON OR BEFORE OCTOBER 7, 2016,
OR YOUR CLAIM FOR PAYMENT WILL BE REJECTED.
If you have questions about this Claim Form visit www.adderallxrsettlement.com,
email [email protected] or call the Settlement Administrator at 877-369-4085
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