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Program Details

MALLINCKRODT
Covidien/Mallinckrodt Patient Assistance Program

Pennsaid Topical Solution (diclofenac sodium)
 
CONTACT INFO
Address: MaxCare
PO Box 18204
Oklahoma City, OK 73154
Phone: 1-800-259-7765 Provider Phone:
Fax: 1-405-525-7523 Website:
ELIGIBILITY
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
    APPLICATION
    Attachments Required:
    Physician License #
    Required:
    Not Required
    Prescriber Signature
    Allowed:
    Not required
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Patient
    MEDICATION
    Receives: Pharmacy Card
    Shipped To: Patient
    Quantity in Shipment: Pharmacy card can be used with prescription once per month.
    Delivery Time:
    Re-application Policy: New application every 12 months
    Refill Policy:
    Other Information:
  • If accepted, the patient must pay a $20 co-pay each time pharmacy card is used.
  • Last Updated: 03/01/2013

     

     

     


    Application Forms
    & Instructions

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


    DocumentForm (English)



     

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