Phillips & Garcia, LLC - Tamoxifen Report Form

<<Tamoxifen Facts

Dear Tamoxifen User:

We believe many insurance companies may be overcharging patients on their co-pays when they buy tamoxifen. We currently have a nationwide class action pending against one insurance company and its prescription drug management company, PCS, for the mis-classification of tamoxifen as a brand name drug.

We are trying to determine the scope of this problem and need your help.Please fill out this form and submit it to us. We will then evaluate the information and let you know whether we think your insurer mis-classified tamoxifen.

If you have questions, e-mail cphillips@phillipsgarcia.com or call our toll free number: 1-877-892-5620.

Thank you!

Your Name

Your Mailing Address

City

State,
Zip Code

Telephone Number (Daytime)

(Evening)

E-mail address

Please answer the following questions to the best of your knowledge: What is the name and address of your health insurance company?

What is the name and address of the company (or companies) that processes or processed your prescription drugs (if different from your insurance company)?

Under your insurance policy (or policies), how is tamoxifen classified? Usually, you have these choices:
Non-Preferred Brand Name Drug
(usually the highest co-pay)
Preferred Brand Name Drug
(usually a moderate co-pay)
Brand Name (usually an increased co-pay)
Generic Drug
(usually a low co-pay, sometimes no co-pay at all)

Do you think you are being overcharged on your tamoxifen co-payments?
Yes No

What is the amount of the co-pay you pay when you purchase tamoxifen (by mail or at a pharmacy)?

What type of a prescription drug co-payments are you required to make under your health plan:
A percentage of drug costs for brand name drugs and no co-pay for generic drugs
A tiered co-payments based structure based on whether the drug is generic, preferred brand name or non-preferred brand name;
No fee
A fixed, flat fee for each drug purchase