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Patient Assistance Information

 
2 Programs for Restoril
 
 
Mallinckrodt Patient Assistance Program

MaxCare
PO Box 18204
Oklahoma City, OK 73154
Phone : 800-259-7765 Ext OPT 2
Fax: 405-525-7523
Eligibility
> The patient must have no prescription coverage for the requested medication and meet income guidelines that are not disclosed.
Who Can Apply
> With the patient's permission, anyone concerned can call for an application.
Required
> The doctor needs to provide a prescription to the patient. The patient must fill out a section and sign the application.
Supply
> Pharmacy card to be used once a month.
Ship To
> Patient's home
Note
> With the patient's permission, anyone concerned can call for an application.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Restoril
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader
 
 
Xubex Pharmaceutical Services

PO Box 1244
Winter Park, FL 32790-1244
Phone : 866-699-8239
Fax: 407-671-7960
Eligibility
> The patient must have an income at or below 243% of the Federal Poverty Level.
Who Can Apply
> Anyone requesting assistance can call to request a faxed application or download it from the website.
Required
> The doctor needs to provide a prescription to the patient.The patient must fill out a section and sign the application.
Supply
>
Ship To
> Either Doctor's office or Patient's home
Note
> Anyone requesting assistance can call to request a faxed application or download it from the website.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Restoril
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader