How to Apply

Once you’ve determined that HealthWell offers assistance for your disease and that you are eligible for assistance, it’s time to apply. The application process is free.  Patients on their own or patients with their provider or advocate can apply to HealthWell two ways:

• Online. To get started, click here
• By phone, call (800) 675-8416

Grant Request Checklist - PLEASE READ!

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 from the same fund)

Step 1
Complete the online application or provide the information to an agent when you call.

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

• Complete Statement of Treatment with the prescribing provider’s signature
• A copy of the patients insurance and pharmacy card(s) – front and back.
• If requesting premium assistance, also include: 
  • Documentation from your insurer or employer confirming the portion of the health insurance premium you are responsible for paying  
  • Documentation that your insurance will cover the medications for the disease state. You may submit 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 day of pre-approval or your grant will close 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.