Apply for Patient

Providers and patient advocates can apply on behalf of a patient online. To get started, click here.

Note: We require patient attestation prior to phone approval; patients on their own or patients with their provider or advocate can apply to HealthWell by phone by calling (800) 675-8416.

Grant Request Checklist - PLEASE READ!

Tips for Working Efficiently with HealthWell - PLEASE READ!

It is free to apply.  Before you begin the application process, please have the following information handy:

• Patient contact information (name, address, telephone number, social security number, date of birth)
• Patient insurance and prescription information and ID (i.e., insurance and pharmacy card(s))
• Patient income information (total household income, total household size)
• Prescribing physician information (name, address, telephone number, fax number, contact name)
• Whether the patient is applying for copayment or premium assistance (can only receive one or the other)

Step 1
Complete the online application.

Step 2
If approved, submit the following required documentation within 30 days:

• Complete Statement of Treatment with the prescribing provider’s signature
• A copy of the patient’s insurance and pharmacy card(s) – front and back.
• If requesting premium assistance, also include:
  • Documentation from the patient’s insurer or employer confirming the portion of the health insurance premium the patient is responsible for paying 
  • Documentation that the patient’s insurance will cover the medications for the disease state.  We accept any of the following:
    • Letter from insurer, or
    • Explanation of Benefits (EOB) form (must include patient name, insurer name, drug name and copay amount), or
    • Recent pharmacy receipt (must include patient name, insurer name, drug name and copay amount)

We must receive ALL the required documentation within 30 days of approval or your grant will be closed and you cannot re-apply for a grant until the next calendar year.  Dates of service and costs incurred prior to the most recent approval date WILL NOT BE ELIGIBLE FOR REIMBURSEMENT.

NOTE: we will not call or send letters requesting any missing required documentation. It is the responsibility of the patient and provider to ensure we received the required documentation within 30 days of the approval.

For fastest service, please fax these items to us at (800) 282-7692, but if you do not have access to a fax machine, you may mail us these materials to: HealthWell Foundation, P.O. Box 4133, Gaithersburg, MD 20878.

To check on the status of a grant, call (800) 675-8416 and follow the instructions.

To see the eligibility criteria, please click here.
If you are ready to begin the application process, please click here.
Have a question? Please visit our FAQ page.

Next Steps

When a Patient is Approved

After approval, we will send the patient an approval letter with the approval date and grant amount, however, there is still ACTION REQUIRED.  This letter outlines the documentation we require and will include a blank Statement of Treatment for the provider to complete.  In addition, if the provider’s fax is given to us, we will fax the Statement of Treatment with cover sheet to the provider’s office.

NOTE: this is the only notification sent regarding the required documentation to both the patient and provider.  We will no longer call or send letters requesting any missing required documentation.  It is the responsibility of the patient and provider to ensure we received the required documentation within 30 days of the approval.

Once we have received the required documentation, we will send the patient a second approval letter titled “APPROVED.”  This letter will provide the patient with a Reimbursement Request Form (RRF) and instructions for submitting for reimbursement OR a pharmacy card (fund appropriate).  In addition, we will fax a copy of the second approval letter to the provider.

When approved, the Foundation allocates each patient a grant for full or partial assistance through December 31. Patients or their providers then submit invoices or receipts to receive reimbursement. The foundation typically sends awards directly to the insurer, pharmacy, physician, or other provider. However, in some cases it may send awards directly to patients to reimburse them for expenses they must pay themselves.

In some cases, patients may receive a HealthWell pharmacy card that they can take to their pharmacy when they fill their prescription. Most pharmacies can accept the card to pay the patient’s copayment at the time of dispensing. In these cases, no reimbursement is necessary. The HealthWell pharmacy card also works with most mail order or specialty pharmacies.

The HealthWell Foundation does not restrict the medications that patients use as long as the medication is approved by the Food and Drug Administration and is being used to treat a condition that falls within a funded area. However, we do focus on helping patients with extreme treatment costs and therefore typically do not reimburse for very low cost treatments, such as generics and steroids. When these lower cost treatments represent a financial hardship to a particular patient, they may be reimbursed on an exception basis.

The Foundation also does not restrict the provider or pharmacy that the patient selects, and patients are free to change providers or pharmacies at any time without affecting a patient’s eligibility for assistance.

The HealthWell Foundation reserves the right to change its program in its entirety or with respect to any applicant at any time with or without notice.

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