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This is a discount card program.
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| Pharmaceutical Company |
Mallinckrodt |
| Program Name |
Mallinckrodt Patient Assistance Program |
| Program Address |
MaxCare
PO Box 18204
Oklahoma City, OK 73154 |
| Phone Number |
800-259-7765, opt 2
405-525-5248
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| Fax Number |
405-525-7523 |
| Medications on Program |
Tofranil Tablets 10mg, 25mg, 50mg (imipramine)
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| Application Forms |
Mallinckrodt Patient Assistance Program
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On-line Application
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No on-line application available at this time |
| Web Site |
No link available. |
| Eligibility Guidelines and Notes |
The patient must have no prescription coverage for the requested medication and meet income guidelines that are not disclosed. Medical diagnosis necessary for this program is not specified. US residency requirements are
not specified. If accepted, the patient must pay a co-pay of $20.
Imipramine, the generic version of Tofranil-PM, is also available.
No decision has been made about patients who are eligible for Medicare Part D but have not enrolled. The patient should still apply. If patient meets other guidelines they may be able to assist those in the donut hole.
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| Application Process |
With the patient's permission, anyone concerned can call for an application. The application can be either faxed or mailed out upon request. The completed application can be faxed or mailed back.
The patient is notified of eligibility for the program.
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| Application Requirements |
The doctor needs to provide a prescription to the patient. The patient must fill out a section and sign the application.
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| Program Details |
The patient is sent a pharmacy card to be used once a month. Once a year the application process must be repeated.
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| Last Updated |
September 29, 2009 |
