Wellwise and Non-Smoker Incentives Form


If you were enrolled in the Wellwise Retiree 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 2017 Retiree Wellwise Incentives Q&A (PDF, 27 KB.)

Submission Deadlines

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

Wellwise Incentive Criteria
You must declare under the penalty of perjury that:
  • I was enrolled in the Wellwise Retiree 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.
Non-Smoker Incentive Criteria
This incentive is available to retirees only. Retirees must have been a Non-Smoker for the twelve-month period of, January 1 through December 31, 2017, to claim the $50 Non-Smoker incentive. You will be eligible to receive the entire $50 Non-Smoker Incentive even if you were only enrolled in the Wellwise Retiree plan for part of 2017.

Wellwise and Non-Smoker Incentives Affidavit

Confirm your eligibility for the Wellwise and/or Non-Smoker Incentive(s) 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.