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      Patient Assistance Program Center

Program Details

Covidien/Mallinckrodt Patient Assistance Program

Address: MaxCare
PO Box 16430
Oklahoma City, OK 73113
Phone: 1-800-259-7765 Provider Phone:
Fax: 1-405-213-1521 Website:
Eligibility Info:
  • Patient must not have prescription coverage for requested medication and must meet program income guidelines which are not disclosed.
  • Patients with Medicare Part D should still apply as assistance might be available.
  • Income at or below: Not Published
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Yes
    US citizenship/residency specified: Not Published
    Attachments Required:
    Physician License #
    Not Required
    Prescriber Signature
    Not required
    Application may be
    Eligibility determination
    letter sent:
    Receives: Pharmacy Card
    Shipped To: Patient
    Quantity in Shipment: Varies by medication
    Delivery Time: Not Published
    Re-application Policy: New application every 12 months
    Refill Policy: Pharmacy card can be used with prescription once per month.
    Other Information:
  • If accepted, the patient must pay a $20 co-pay each time pharmacy card is used.
  • Last Updated: 04/11/2018




    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.

    DocumentForm (English)


    Print-friendly version

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