Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 2.
Scroll down to see them all.
Updated October 06, 2014
 

Restoril

Covidien/Mallinckrodt Patient Assistance Program

This is a discount card program.

Provided by: Mallinckrodt

MaxCarePO Box 16430
Oklahoma City, OK 73113

TEL: 800-259-7765, opt. 2


ALT PHONE: 405-525-5248
FAX: 405-525-7523
Languages Spoken:

English

 

Patient Assistance Applications

Covidien/Mallinckrodt Patient Assistance Program Application Form

 

Medications

  • Restoril Capsule 7.5mg, 15mg, 30mg (temazepam)
 

Eligibility Requirements   

Insurance Status Uninsured or Underinsured with no prescription coverage for needed medication
Those with Part D Eligible? Yes
Income Not disclosed
Diagnosis/Medical Criteria Not specified
US Residency Required? Not specified
   

Application

Obtaining Call
Receiving Faxed, emailed or downloaded from website
Returning Fax or mail
Doctor's Action Give prescription to patient
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient notified
Decision Timeframe Not specified
   

Medication

Amount/Supply Up to a 30 day supply or 90 Qty
Sent To Patient sent card to be used at pharmacy
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application New application yearly
   

Additional Information

For the medication Exalgo, the quantity is 120.

For the medication Roxicodone, the quantity is 360 for the 15mg and 180 for the 30mg.

If accepted, the patient must pay a copay of $20.
Contact program for Spanish application.


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 2. Updated December 11, 2014
 

Restoril

Rx Outreach Medications

This program provides medication at low cost.

Provided by: Rx Outreach

PO Box 66536
St Louis, MO 63166-6536

TEL: 888-796-1234


ALT PHONE:
FAX: 800-875-6591
Languages Spoken:

English, Spanish

Program Website

 

Patient Assistance Applications

Rx Outreach Application

Rx Outreach Diabetic Supplies

Rx Outreach Refills and New Prescriptions Order Form

Rx Outreach Medication List

 

Medications

  • Restoril Capsule 15mg, 30mg (temazepam)
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income At or below 300% of FPL
Diagnosis/Medical Criteria Not required
US Residency Required? Must reside in the US
   

Application

Obtaining Call, download or apply online
Receiving Faxed or mailed
Returning Fax or E-Prescribe online
Doctor's Action Give prescription to patient
Applicant's Action Complete section and sign
Decision Communicated Medications sent if accepted. If denied patient and doctor notified
Decision Timeframe Usually same day
   

Medication

Amount/Supply Varies
Sent To Doctor's office or patient's home
Delivery Time Not specified
Refill Process Company contacts patient to arrange
Limit Only limited by manufacturer's guidelines
Re-application New application yearly
   

Additional Information

Some medications are available for a fee of $20 for up to a 180 day supply.
Check the Rx Outreach website for the exact price and most current medication list.
Contact Program for Spanish Application(s)/Form(s)