Wellwise Non-Smoker Incentives Form

Retirees


If you were enrolled in the Wellwise Retiree Health Plan in 2017 but did not qualify for the Wellwise Incentive, you are eligible to file a claim for the $50 Non-Smoker Incentive if you were a non-smoker for the entire 2017 calendar year.  For more information, please download the 2017 Retiree Wellwise Incentives Q&A (PDF, 92 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.


Non-Smoker Incentive Criteria



This incentive is available to retirees only. Retirees must have been a Non-Smoker for the twelve-month period, 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.

Non-Smoker Incentive Affidavit Form



Confirm your eligibility for the 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.