Pediatric Assistance Fund

Status

Open

Assistance Type

Prescription Drug Copay

Maximum Award Level

$2,500

Pharmacy Card Fund

Yes

Minimum Copay Reimbursement Amount

None

Minimum Premium Reimbursement Amount

None

Household Income Limit

500% of the Federal Poverty Level
(adjusted for household size and high cost of living areas)

Fund Alerts

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Treatments Covered

Acute Lymphoid Leukemia

Adriamycin
Alkindi Sprinkle
Amerinet Choice Carboplatin
Arranon
Asparaginase Erwinia Chrysanthemi*
Asparlas
Besponsa
Betamethasone
Betamethasone Acetate-betamethasone Sodium Phosph
Betamethasone Sod Phos-betamethasone Ace Novaplus
Betamethasone Sodium Phosphate-betamethasone Ace
Blincyto
Bortezomib
Carboplatin
Carboplatin N+ Novaplus
Carboplatin Novaplus
Celestone Soluspan
Clofarabine
Clolar Novaplus
Cortef
Cortisone Acetate
Cyclophosphamide
Cyclophosphamide Monohydrate
Cyclophosphamide Novaplus
Cytarabine
Darzalex
Daunorubicin Hcl
Daunorubicine Hcl Novaplus
Decadron
Depo-medrol
Depo-medrol Novaplus
Dexabliss 11-day Dose Pack
Dexamethasone
Dexamethasone Intensol
Dexamethasone Micronized
Dexamethasone Sodium Phosphate
Dexamethasone Sodium Phosphate Novaplus
Dexamethasonetherapy Pack
Dexevo
Dexonto
Dexrazoxane
Dexrazoxane Novaplus
Dextenza
Dexycu
Doxorubicin Hcl
Doxorubicin Hcl Novaplus
Erwinase*
Etopophos
Etoposide
Etoposide Novaplus
Fludarabine Phosphate
Fludarabine Phosphate Novaplus
Fusilev
Gleevac
Hemady
Hidex
Hydrocortisone
Hydrocortisone Avpak
Iclusig
Idamycin Pfs
Idarubicin Hcl Novaplus
Idarubicin Hydrochloride
Ifex
Ifosfamide
Ifosfamide Novaplus
Imatinib Mesylate
Jakafi
Jylamvo
Kenalog-10
Kenalog-40
Kenalog-80
Khapzory
Kymriah
Leucovorin Calcium
Leucovorin Calcium Novaplus
Levoleucovorin Calcium
Maxidex
Medrol
Medrol Dosepak
Mercaptopurine
Mercaptopurine Monohydrate
Mesna
Mesna Novaplus
Mesnex
Methotrexate
Methotrexate Avpak
Methotrexate Novaplus
Methotrexate Sodium
Methylprednisolone
Methylprednisolone Acetate
Methylprednisolone Acetate Novaplus
Millipred
Mitoxantrone Hcl
Nelarabine
Nelarabine Novaplus
Oncaspar
Orapred Odt
Otrexup
Ozurdex
Paraplatin
Pediapred
Prednisolone
Prednisolone Anhydrous
Prednisolone Micronized
Prednisolone Sodium Phosphate
Prednisone
Prednisone Anhydrous
Prednisone Intensol
Premier Pro Rx Betamethasone Na Phos-betameth Ace
Premierpro Rx Carboplatin
Premierpro Rx Cyclophosphamide
Premierpro Rx Dexamethasone Sodium Phosphate
Premierpro Rx Doxorubicin Hcl
Premierpro Rx Leucovorin Calcium
Premierpro Rx Mesna
Premierpro Rx Methotrexate
Premierpro Rx Methylprednisolone Acetate
Premierpro Rx Triamcinolone Acetonide
Pro-c-dure 5 Kit
Pro-c-dure 6 Kit
Purixan
Rasuvo
Rayos
Readysharp Betamethasone
Riabni
Rituxan
Ruxience
Rylaze
Simplist Dexamethasone Sodium Phosphate
Simplist Dexamethasone Sodium Phosphate +rfid
Solu-cortef
Solu-cortef 100mg Vial
Solu-cortef 250mg Vial
Solu-cortef 500mg Vial
Sprycel
Tabloid
Taperdex
Taperdex 6-day
Taperdex 7-day
Tasigna
Teniposide*
Thioguanine
Totect
Trexall
Triamcinolone Acetonide
Triamcinolone Acetonide Novaplus
Triesence
Truxima
Velcade
Venclexta
Venclexta Starter Pack
Veripred 20
Vincristine Sulfate
Vincristine Sulfate Novaplus
Vp-16
Xatmep
Zcort 7-day
Zilretta

Autism Spectrum Disorder (including ADD and ADHD)

Abilify
Abilify Asimtufii
Abilify Maintena Dual-chambered Syringe
Abilify Maintena Vial
Abilify Mycite Maintenance Kit
Abilify Mycite Starter Kit
Adasuve
Adderall
Adderall Xr
Adzenys Xr Odt
Amantadine Hcl
Amantadine Hcl Avpak
Amphetamine Salt Combination
Amphetamine Sulfate
Anafranil
Aptensio Xr
Aripiprazole
Aripiprazole Avpak
Aristada
Aristada Initio
Atomoxetine Avpak
Atomoxetine Hydrochloride
Azstarys
Behavioral Therapy Services*
Bupropion Hcl
Bupropion Hcl Avpak
Bupropion Hcl Xl
Bupropion Hydrochloride Sr
Catapres-tts-1
Catapress-tts-2
Catapress-tts-3
Chlorpromazine Hcl
Chlorpromazine Hcl Avpak
Clomipramine Hcl
Clonidine
Clonidine Hcl
Clonidine Hcl Avpak
Concerta
Cotempla Xr-odt
Counseling Services*
Daytrana
Desipramine Hcl
Dexedrine Spansule
Dexmethylphenidate Hcl
Dexmethylphenidate/serdexmethylphenidate*
Dextroamph Sacc-amph Asp-dextroam Sulf-amphet Sulf
Dextroamphetamine Sulfate
Duraclon
Dyanavel Xr
Effexor Xr
Escitalopram
Escitalopram Oxalate
Evekeo
Fluoxetine
Fluoxetine Hcl
Focalin
Focalin Xr
Forfivo Xl
Geodon
Gocovri
Guanfacine Hcl
Guanfacine Hcl Avpak
Haldol Deconate
Haloperidol
Haloperidol Amerinet Choice
Haloperidol Decanoate 50
Haloperidol Decanoate Novaplus
Haloperidol Deconate
Haloperidol Lactate
Imipramine Hcl
Imipramine Pamoate
Intuniv
Invega
Invega Hafyera
Invega Sustenna
Invega Trinza
Jornay Pm
Lexapro
Lisdexamfetamine Dimesylate
Lithium
Lithium Carbonate
Lithium Citrate
Lithobid
Loxapine
Loxapine Succinate
Metadate Cd
Metadate Er
Methamphetamine
Methamphetamine Hcl
Methylin
Methylphenidate
Methylphenidate Hcl
Methylphenidate Hcl Avpak
Methylphenidate Hcl Cd
Methylphenidate Hcl La
Mixed Amphetamine Salt
Modafinil
Modafinil Avpak
Mydayis
Nexiclon Xr
Nortriptyline Hcl
Nortriptyline Hcl Avpak
Occupational Therapy Services*
Olanzapine
Olanzapine Avpak
Onyda Xr
Osmolex Er
Osmolex Er Dosing Kit
Paliperidone
Pamelor
Pemoline*
Perseris
Physical Therapy Services*
Pimozide
Premierpro Rx Geodon
Premierpro Rx Haldoperidol
Premierpro Rx Haloperidol Decanoate
Premierpro Rx Olanzapine
Procentra
Provigil
Prozac
Qelbree
Quetiapine
Quetiapine Fumarate
Quetiapine Fumarate Avpak
Quillichew Er
Quillivant Xr
Relexxii
Risperdal
Risperdal Consta
Risperidone
Risperidone M-tab
Risperidone Odt
Ritalin
Ritalin La
Rykindo
Seroquel
Seroquel Xr
Seroquel Xr 14-day Sample Kit
Simplist Haloperidol
Speech Therapy Services*
Strattera
Uzedy
Valproic Acid
Venlafaxine
Venlafaxine Hcl
Venlafaxine Hcl Avpak
Vyvanse
Wellbutrin Sr
Wellbutrin Xl
Xelstrym
Zenzedi
Ziprasidone Hcl
Ziprasidone Hcl Avpak
Ziprasidone Mesylate
Zyprexa
Zyprexa Intramuscular
Zyprexa Zydis

Congenital Heart Disease

7t Gummy Es
Acetaminophen (iv)
Acetaminophen Novaplus
Acetylsalicyclic Acid
Adempas
Alprostadil
Ambrisentan
Arymo Er
Asprin
Bosentan
Caldolor
Caverject
Caverject Impulse
Cyklokapron
Dextrose/morphine Sulfate
Dilantin
Dilantin Infatabs
Dilantin-125
Duramorph
Durlaza
Edecrin
Edex
Ethacrynic Acid
Hemangeol
Ibu
Ibuprofen
Ibuprofen Lysine
Inderal La
Inderal Xl
Indocin
Indomethacin
Indomethacin Avpak
Indomethacin Novaplus
Infatabs Phenytoin
Infumorph 200
Infumorph 500
Innopran Xl
Inomax
Kadian
Letairis
Mitigo
Morphine Sulfate
Morphine Sulfate In 5% Dextrose
Morphine Sulfate-sodium Chloride
Morphine-dextrose
Morphine-sodium Chloride
Ms Contin
Muse
Neoprofen
Ofirmev
Opsumit
Orenitram
Orenitram Titration Kit Month 1
Orenitram Titration Kit Month 2
Orenitram Titration Kit Month 3
Phenytek
Phenytoin
Phenytoin Sodium
Phenytoin Sodium Extended
Phenytoin Sodium Extended Avpak
Phenytoin Sodium Novaplus
Premierpro Rx Acetaminophen
Premierpro Rx Indomethacin
Premierpro Rx Tranexamic Acid
Propanolol Hcl
Propranolol Hcl Avpak
Prostin Vr Pediatric
Prostin Vr Pediatric Novaplus
Remodulin
Revatio
Sildenafil
Sildenafil Avpak
Sildenafil Citrate
Simplist Morphine Sulfate Microvault
Tivorbex
Tracleer
Tranexamic Acid
Tranexamic Acid Avpak
Tranexamic Acid Novaplus
Tranexamic Acid-sodium Chloride
Treprostinil
Tyvaso
Tyvaso Dpi
Tyvaso Dpi Institutional Kit
Tyvaso Dpi Titration Kit
Uptravi
Viagra
Xarelto
Xarelto Starter Pack

Convergence Insufficiency

Prescription Frames For Glasses*
Prescription Lenses For Glasses*

Diabetes (Types I and II)

Acarbose
Admelog
Admelog Solostar Pen
Apidra
Apidra Solostar
Baqsimi
Basaglar Kwikpen
Basaglar Tempo Pen
Bd Dextrose
Bydureon Bcise
Byetta 10mcg Pen
Byetta 5mcg Pen
Dapagliflozin Propanediol
Dapagliflozin Propanediol-metformin Hcl
Dexcom Cgm
Dextrose
Dextrose Anyhydrous
Dextrose Monohydrate
Dm2
Farxiga
Fiasp
Fiasp Flextouch
Fiasp Penfill
Fiasp Pumpcart
Glucagen
Glucagen Diagnostic Kit
Glucagon
Glucagon Emergency Kit
Glucagon Novaplus
Glucophage
Glucophage Xr
Glumetza
Gvoke Hypopen 1 Pack
Gvoke Hypopen 2 Pack
Gvoke Kit
Gvoke Pfs 1 Pack
Gvoke Pfs 2 Pack
Humalog
Humalog Junior Kwikpen
Humalog Kwikpen
Humalog Mix 50/50
Humalog Mix 50/50 Kwikpen
Humalog Mix 75/25
Humalog Mix 75/25 Kwikpen
Humalog Tempo Pen
Humulin 70/30
Humulin 70/30 Kwikpen
Humulin N (nph)
Humulin R
Humulin R Concentrated U-500
Humulin R Concentrated U-500 Kwikpen
Humunlin N (nph) Kwikpen
Insulin Aspart
Insulin Aspart Flexpen
Insulin Aspart Penfill
Insulin Aspart Prot-insulin Aspart 70/30 Flexpen
Insulin Aspart Protamine/insulin Aspart 70/30
Insulin Aspart/insulin Aspart Protamine
Insulin Degludec
Insulin Degludec Flextouch Pen
Insulin Glargine
Insulin Glargine Pen
Insulin Glargine U-300 Max Solostar
Insulin Glargine U-300 Solostar
Insulin Human Regular/insulin Human Isophane (nph)*
Insulin Lispro
Insulin Lispro Junior Kwikpen
Insulin Lispro Kwikpen
Insulin Lispro Protamine/ins Lispro 75/25 Kwikpen
Insulin Lispro/insulin Lispro Protamine
Jardiance
Lantus
Lantus Solostar Pen
Levemir
Levemir Flexpen
Liraglutide
Lyumjev Kwikpen U-100
Lyumjev Kwikpen U-200
Lyumjev Tempo Pen
Lyumjev U-100
Metformin Hcl
Metformin Hcl Avpak
Metformin Hydrochloride
Metformin/dapagliflozin
Metformin/empagliflozin
Myxredlin
Novolin 70/30
Novolin 70/30 Flexpen
Novolin N (nph)
Novolin N Flexpen
Novolin R
Novolin R Flexpen
Novolog
Novolog Flexpen
Novolog Mix 70/30
Novolog Mix 70/30 Flexpen
Omnipod
Precose
Relion Novolin 70/30
Relion Novolin 70/30 Flexpen
Relion Novolin N Flexpen
Relion Novolin R
Relion Novolin R Flexpen
Relion Novolog
Relion Novolog Flexpen
Relion Novolog Mix 70/30
Relion Novolog Mix 70/30 Flexpen
Rezvoglar Kwikpen
Riomet
Riomet Er
Saxenda
Semglee
Semglee Pen
Synjardy
Synjardy Xr
Toujeo 1.5ml Prefilled Pen
Toujeo Max 3ml Prefilled Pen
Tresiba
Tresiba Flextouch Pen
Trulicity
Tzield
Victoza
Xigduo Xr
Zegalogue

*These products are not billable through HealthWell’s pharmacy card. Please submit requests for reimbursement through our paper claim process.

Fund Definition

Assistance with the cost shares of prescription drugs, therapies, devices, and transportation related to eligible disease states (Acute Lymphoid Leukemia, Autism Spectrum Disorder (including ADD and ADHD), Congenital Heart Disease, Convergence Insufficiency, Diabetes (Types I and II).

Grant Utilization

HealthWell estimates that patients use an average of $1,500 during their 12-month grant period for this disease area.

Do I Qualify?

HealthWell bases eligibility on an individual’s medical, financial and insurance situation. To qualify for HealthWell’s assistance, applicants must meet the following eligibility requirements:

To find out if you are eligible for HealthWell’s Pediatric Assistance Fund, please contact us at (800) 675-8416 to speak with a HealthWell representative or apply online. We can only assist with medications that have been prescribed to treat the disease/covered diagnosis. You will be asked to provide the Foundation with the patient’s diagnosis, which must be verified by a physician, nurse practitioner, or physician assistant’s signature. The patient must receive treatment in the United States.
To qualify for assistance from HealthWell, you must have some form of health insurance (private insurance, Medicare, Medicaid, TriCare, etc.) that covers part of the cost of your treatment. The Foundation will refer patients without prescription insurance to other programs, such as manufacturer patient assistance programs.
HealthWell assists individuals with incomes up to 300-500% of the Federal Poverty Level. The Foundation also considers the number in a household and cost of living in a particular city or state. If you believe you qualify for assistance, please call (800) 675-8416 to speak with a HealthWell representative.
If you are receiving treatment in the U.S. and have met the eligibility criteria as listed, you are ready to apply! Please note that you will be asked to provide a Social Security Number in order to create a grant. This information is gathered to eliminate duplicate applications and is kept secure and confidential.

Apply Re-Enroll

Solicitar

To apply for a grant through our Pediatric Assistance Fund, you can contact a HealthWell representative at 1-800-675-8416 or apply online. We wish we could say “yes” to every family that comes to us, however, funding is limited. Families must meet HealthWell’s standard income and insurance eligibility criteria to qualify for a grant. Grants are awarded through the Pediatric Assistance Fund. To apply for a grant, call 1-800-675-8416 anytime Monday through Friday, 9:00 a.m. to 5:00 p.m. (ET).

About HealthWell’s Pediatric Assistance Fund

HealthWell’s Pediatric Assistance Fund helps children access the medical treatments they need for specific diseases or conditions. Through the fund, HealthWell is able to assist families in meeting their cost-sharing obligations for conditions covered under the fund to help their child start or continue treatments they otherwise would not be able to afford.

You may also visit our Resource List to view other copayment organizations that may provide assistance.

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