Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
 

Restoril

Covidien/Mallinckrodt Patient Assistance Program

This is a discount card program.

Provided by: Mallinckrodt

Attn: MaxCare
PO Box 16430
Oklahoma City, OK 73113

TEL: 800-259-7765, opt. 3


ALT PHONE: 405-525-5248
FAX: 405-213-1521
Languages Spoken:

English

 

Program Applications and Forms

Covidien/Mallinckrodt Patient Assistance Program Application

 

Medications

  • Restoril capsule (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.


Updated April 07, 2016