Pediatric Assistance Fund

Status

Closed

Assistance Type

Prescription Drug Copay

Maximum Award Level

$2,500

Payment Type

Pharmacy Card

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

Kyxata
Tandem Mobi Pump
Transportation - Car Mileage

Acute Lymphoid Leukemia

Adriamycin
Alkindi Sprinkle
Allopurinol
Amerinet Choice Carboplatin
Arranon
Asparaginase Erwinia Chrysanthemi Recombinant-rywn
Asparaginase Erwinia Chrysanthemi*
Asparlas
Besponsa
Betamethasone
Betamethasone Acetate-betamethasone Sodium Phosph
Betamethasone Sod Phos-betamethasone Ace Novaplus
Betamethasone Sodium Phosphate-betamethasone Ace
Blinatumomab
Blincyto
Bortezomib
Boruzu
Calaspargase Pegol-mknl
Carboplatin
Carboplatin N+ Novaplus
Carboplatin Novaplus
Celestone Soluspan
Clofarabine
Clolar Novaplus
Cortef
Cortisone Acetate
Cyclophosphamide
Cyclophosphamide Monohydrate
Cyclophosphamide Novaplus
Cytarabine
Danziten
Daratumumab
Darzalex
Dasatinib
Daunorubicin Hcl
Daunorubicine Hcl Novaplus
Defibrotide Sodium
Defitelio
Depo-medrol
Depo-medrol Novaplus
Dex24
Dexabliss 11-day Dose Pack
Dexamethasone
Dexamethasone Intensol
Dexamethasone Micronized
Dexamethasone Sodium Phosphate
Dexamethasone Sodium Phosphate Novaplus
Dexamethasonetherapy Pack
Dexevo
Dexonto 0.4%
Dexrazoxane
Dexrazoxane Novaplus
Dextenza
Doxorubicin Hcl
Doxorubicin Hcl Novaplus
Etopophos
Etoposide
Etoposide Novaplus
Etoposide Phosphate
Fludarabine Phosphate
Fludarabine Phosphate Novaplus
Frindovyx
Gleevac
Hemady
Hydrocortisone
Hydrocortisone Avpak
Hydrocortisone Sodium Succinate
Iclusig
Idamycin Pfs
Idarubicin Hcl Novaplus
Idarubicin Hydrochloride
Ifex
Ifosfamide
Ifosfamide Novaplus
Imatinib Mesylate
Imkeldi
Inotuzumab Ozogamicin
Jakafi
Jylamvo
Kenalog-10
Kenalog-40
Kenalog-80
Khapzory
Khindivi
Kymriah
Lederle Leucovorin
Leucovorin Calcium
Leucovorin Calcium Novaplus
Levoleucovorin
Levoleucovorin Calcium
Marqibo
Maxidex
Medrol
Medrol Dosepak
Mercaptopurine
Mercaptopurine Monohydrate
Mesna
Mesna Novaplus
Mesnex
Methotrexate
Methotrexate Avpak
Methotrexate Novaplus
Methotrexate Sodium
Methylprednisolone
Methylprednisolone Acetate
Methylprednisolone Acetate Novaplus
Methylprednisolone Sodium Succinate
Millipred
Mitoxantrone Hcl
Nelarabine
Nelarabine Novaplus
Nilotinib
Oncaspar
Orapred Odt
Ozurdex
Pediapred
Pegaspargase
Phyrago
Ponatinib Hydrochloride
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
Readysharp Betamethasone
Reltone
Revuforj
Revumenib
Riabni
Rituxan
Rituximab
Rituximab-abbs
Rituximab-arrx
Rituximab-pvvr
Ruxience
Ruxolitinib Phosphate
Rylaze
Simplist Dexamethasone Sodium Phosphate
Simplist Dexamethasone Sodium Phosphate +rfid
Solu-cortef
Solu-cortef 1000mg Vial
Solu-cortef 100mg Vial
Solu-cortef 250mg Vial
Solu-cortef 500mg Vial
Solu-medrol
Sprycel
Tabloid
Taperdex
Taperdex 6-day
Taperdex 7-day
Tasigna
Thioguanine
Tisagenlecleucel
Trexall
Triamcinolone Acetonide
Triamcinolone Acetonide Novaplus
Truxima
Urso Forte
Ursodiol
Velcade
Venclexta
Venclexta Starter Pack
Venetoclax
Veripred 20
Vincristine Sulfate
Vincristine Sulfate Liposome
Vincristine Sulfate Novaplus
Vp-16
Vykoura
Xatmep
Zyloprim

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
Adderall Xr
Adzenys Xr Odt
Amantadine Hcl
Amantadine Hcl Avpak
Amphetamine Odt
Amphetamine Sulfate
Anafranil
Aptensio Xr
Aripiprazole
Aripiprazole Avpak
Aristada
Aristada Initio
Arynta
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
Clomipramine Hcl
Clonidine
Clonidine Hcl
Clonidine Hcl Avpak
Concerta
Cotempla Xr-odt
Counseling Services*
Daytrana
Dermacinrx Melatol
Desipramine Hcl
Dexedrine Spansule
Dexmethylphenidate And Serdexmethylphenidate
Dexmethylphenidate Hcl
Dextroamphetamine
Dextroamphetamine Sulfate
Dyanavel Xr
Effexor Xr
Erzofri
Escitalopram
Escitalopram Oxalate
Evekeo
Fluoxetine
Fluoxetine Hcl
Focalin
Focalin Xr
Forfivo Xl
Geodon
Gocovri
Guanfacine Hcl
Guanfacine Hcl Avpak
Haldol Deconate
Haloperidol
Haloperidol Decanoate 50
Haloperidol Decanoate Novaplus
Haloperidol Deconate
Haloperidol Lactate
Imipramine Hcl
Imipramine Pamoate
Intuniv
Invega
Invega Hafyera
Invega Sustenna
Invega Trinza
Javadin
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
Modafinil
Modafinil Avpak
Nexiclon Xr
Nortriptyline Hcl
Nortriptyline Hcl Avpak
Occupational Therapy Services*
Olanzapine
Olanzapine Avpak
Olanzapine Pamoate
Onyda Xr
Opipza
Osmolex Er
Osmolex Er Dosing Kit
Paliperidone
Paliperidone Palmitate
Pamelor
Perseris
Physical Therapy Services*
Pimozide
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
Simplist Haloperidol
Speech Therapy Services*
Strattera
Uzedy
Valproic Acid
Venlafaxine
Venlafaxine Hcl
Viloxazine
Vyvanse
Wellbutrin Sr
Wellbutrin Xl
Xelstrym
Zenzedi
Ziprasidone Hcl
Ziprasidone Hcl Avpak
Zyprexa
Zyprexa Intramuscular
Zyprexa Relprevv
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
Entresto
Ethacrynic Acid
Hemangeol
Ibu
Ibuprofen (rx)
Ibuprofen Lysine
Inderal La
Inderal Xl
Indocin
Indomethacin
Indomethacin Avpak
Indomethacin Novaplus
Infatabs Phenytoin
Infumorph 200
Infumorph 500
Innopran Xl
Inomax
Kadian
Letairis
Macitentan
Mitigo
Morphine Sulfate
Morphine Sulfate In 5% Dextrose
Morphine Sulfate-sodium Chloride
Morphine-dextrose
Morphine-sodium Chloride
Ms Contin
Muse
Neoprofen
Nipride Rtu
Nitric Oxide
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 Hydrochloride Avpak
Prostin Vr Pediatric
Prostin Vr Pediatric Novaplus
Remodulin
Revatio
Riociguat
Rivaroxaban
Sacubitril And Valsartan
Selexipag
Sildenafil
Sildenafil Avpak
Sildenafil Citrate
Simplist Morphine Sulfate Microvault
Sodium Nitroprusside
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
Vybrique
Xarelto
Xarelto Starter Pack
Yutrepia

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
Canagliflozin
Canagliflozin And Metformin Hydrochloride
Dapagliflozin Propanediol
Dapagliflozin Propanediol And Metformin Hcl
Dasiglucagon
Dexcom Cgm
Dextrose
Dextrose Anyhydrous
Dextrose Monohydrate
Dm2
Dulaglutide
Empagliflozin
Empagliflozin And Metformin Hydrochoride
Farxiga
Fiasp
Fiasp Flextouch
Fiasp Penfill
Fiasp Pumpcart
Freestyle Libre
Glimepiride
Glimepiride Avpak
Glipizide
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
Gvoke Vialdx
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-szjj, Recombinant
Insulin Aspart-xjhz
Insulin Aspart/insulin Aspart Protamine
Insulin Degludec
Insulin Degludec Flextouch Pen
Insulin Glargine U-300 Max Solostar
Insulin Glargine U-300 Solostar
Insulin Glargine-aglr, Recombinant
Insulin Glargine-yfgn
Insulin Glargine-yfgn Pen
Insulin Glulisine
Insulin Human Isophane (nph)
Insulin Human Regular
Insulin Human Regular And Insulin Human Isophane (nph)
Insulin Lispro
Insulin Lispro And Insulin Lispro Protamine
Insulin Lispro Junior Kwikpen
Insulin Lispro Kwikpen
Insulin Lispro Protamine And Ins Lispro 75/25 Kwikpen
Insulin Lispro-aabc Recombinant
Invokamet
Invokana
Jardiance
Kirsty
Kirsty Pen
Lantus
Lantus Solostar Pen
Liraglutide
Lyumjev Kwikpen U-100
Lyumjev Kwikpen U-200
Lyumjev Tempo Pen
Lyumjev U-100
Merilog
Merilog Solostar
Metformin Hcl
Metformin Hcl Avpak
Metformin Hydrochloride
Metformin/dapagliflozin
Mounjaro
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
Ozempic
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
Rybelsus
Saxenda
Semaglutide
Semglee
Semglee Pen
Synjardy
Synjardy Xr
Teplizumab-mzwv
Tirzepatide
Toujeo 1.5ml Prefilled Pen
Toujeo Max 3ml Prefilled Pen
Tresiba
Tresiba Flextouch Pen
Trulicity
Tzield
Victoza Pen
Wegovy
Xigduo Xr
Zegalogue
Zepbound
Zepbound Kwikpen
Zepbound Pen

*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/disorder 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.

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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