Apply for Patient

Anyone with the patient’s permission may apply for a grant on the patient’s behalf:  

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)
  • Fund to which the patient is applying for assistance
  • Type of assistance patient is requesting (copay or premium, note: not all funds offer premium assistance)

*If the patient does not have a Social Security Number, you will need to call (800) 675-8416 to speak to a HealthWell representative.

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

Step 2
If the patient is approved, via phone or online, we will send an approval letter with the enrollment period dates and grant amount to the patient. The approval letter will provide the patient with a Reimbursement Request Form based on the type of assistance requested and instructions for submitting the reimbursement OR a pharmacy card (fund appropriate). In addition, we will fax a copy of the approval letter to the provider as long as their fax number was provided.

To check on the status of a grant, you can register and use our secure online Provider Portal.

You can see our eligibility page here.
If you are ready to begin, our application page is here.
Have questions? Please visit our FAQ page.