Registered Users Log-in:

E-mail Address:


Forgot Password?
Patient Assistance Information

1 Program for Tofranil Tablets
Covidien/Mallinckrodt Patient Assistance Program

Max Care
PO Box 16430
Oklahoma City, OK 73113
Phone : 800-259-7765 Ext opt3
Fax: 405-213-1521
> Covidien/Mallinckrodt Patient Assistance Program is a discount card program available to uninsured or underinsured patients. Income requirements for this program have not been disclosed.
Who Can Apply
> Patients can call to for an application or print one from the link below.
> Doctors must provide patients with a prescription. Patients must complete, sign, attach a copy of proof of income and fax or mail the application. A new application is needed yearly.
> Up to a 30 day supply or 90 quantity
Ship To
> Patient is sent a card to be used at the pharmacy.
> 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.
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.
Tofranil Tablets
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
Download printable Form
(Requires Acrobat Reader