Actelion Pharmaceuticals $65M Tracleer, Bosentan Settlement

What the form asks

• — Legal name of the third-party payor organization filing the claim (Your organization's legal registration or plan documents)
• — National Drug Code (NDC) number and the drug name (Tracleer or bosentan) for each transaction (Pharmacy claims data, explanation of benefits (EOB) records, or pharmacy benefit manager reports)
• — The date each prescription was filled or purchased (Pharmacy claims data or EOB records)
• — State where the purchase occurred and state where the insured or beneficiary is located (Claims data; for mail-order, use the state where the medication was received)
• — The net dollar amount your organization actually paid for each transaction after subtracting member cost-sharing (Pharmacy claims data or PBM reports showing plan-paid amounts)
• — The plan or group name and Federal Employer Identification Number for each entity on whose behalf the agent is filing (Plan documents or employer tax records)

Documents you'll need

Watch out for

• Individual consumers who purchased the drug for personal use are excluded and cannot file a claim
• Government entities and subsidiaries or affiliates of the defendants are also excluded
• Mail-order purchases are considered to have occurred in the state where the medication was received, not where the pharmacy is located — verify the correct state for each transaction
• Agents filing on behalf of multiple entities must provide written authorization for each entity and include the plan or group name and FEIN per transaction
• The settlement administrator may request additional information or documents if needed, so retain all supporting records
• Payments are distributed only after the court grants final approval and any appeals are resolved — there is no fixed payout date yet