Wellwise Incentive Form

Active Employees, Employees on a Leave of Absence, and those no longer employed by the County

If you were enrolled in the Wellwise Health Plan in 2017 and are eligible for the 2017 Wellwise Incentive, you will receive a letter informing you of your eligibility and instructions on how to submit your affidavit. For more information, please download the Wellwise Incentive Q&A (PDF, 25 KB.)

The date you receive your payout will be based on that date you submit your online affidavit. The first affidavit deadline submission date is May 6, 2018 and the second is July 22, 2018. Any affidavit received after July 22, 2018 may be denied.

Wellwise Incentive Criteria

You must declare under the penalty of perjury that:
  • I was enrolled in the Wellwise Health Plan during 2017.
  • I have not filed any claims outside the Preventive Care Benefit set forth in the Plan Document, for myself and my dependents.
  • I have not filed any other claims for benefits against the Health Plan or the OptumRx Prescription Drug Card and Mail Order Program for services incurred in 2017 for me or my enrolled dependents.

Wellwise Incentive Affidavit

Confirm your eligibility for the Wellwise Incentive by completing and submitting the form below.

Questions about this form?
Call the Blue Shield Customer Service Department at 1-888-235-1767.

Blue Shield of California provides administrative services only and does not assume any financial risk or obligation.