Anthem Health Rewards Health Action Plan

Anthem Health Rewards Health Action Plan
Satisfaction of Wellness Program Alternative Standard

PART 1: REASON FOR THIS FORM
Your employer (or the employer of the person whose name is on the health plan) is offering rewards to employees and their dependents.* You can receive rewards by achieving certain health outcomes. If you were screened for a wellness program with a target health outcome, but were unable to achieve the health outcome for any reason, you may still apply to get the reward. To do so, you and your doctor must certify that you have met and discussed a health action plan that will help you reasonably work toward the health outcome you were unable to meet. Once you have met, you can apply for the reward by filling out your portion of this form and having your doctor complete his or her portion. This form is only good for the current plan year of the employer's program. A new form will need to be completed for each plan year. Please keep a copy of the complete form for your records. A form must be filled out for each Wellness Program Health Outcome for which you are requesting a Health Action Plan.

PART 2: FORM TO BE COMPLETED BY MEMBER ﴾employee or dependent﴿

Last name

First name

Date of birth

Address

City

State

Zip code

Member ID number

Group no.

Health Outcome Program where standard result not met: Tobacco Free

Health Outcome Standard to be met: Not using tobacco products

Your Health Outcome Result: Using tobacco products

By signing this form, I certify that I am not tobacco free and therefore did not achieve the health outcome listed above. I also certify that I have met with my doctor to discuss a health action plan that will help me work towards meeting the health outcome standard. My doctor will confirm this with a signature in Part 3 of this form. I also certify that the information on this form is true and correct.

Member signature X

Print name

Date

PART 3: THIS SECTION IS TO BE COMPLETED BY YOUR DOCTOR

Your patient has indicated he or she has met with you to discuss a health action plan that will help them work towards meeting the health standard listed above. If you agree that a health action plan is in place to support him or her to appropriately work towards the listed health standard, please provide your signature below.

Doctor name

Address

Phone no.

Doctor signature

Date

X

PART 4: AFTER FORM IS COMPLETED, MEMBER SUBMITS FORM TO US
Mail To:

(Colorado, Nevada members) Anthem Blue Cross Blue Shield PO Box 5747 Denver, CO 80217

(Indiana, Ohio, Kentucky, Missouri, Wisconsin members) Anthem Blue Cross Blue Shield PO Box 105557 Atlanta GA 30348­5557

(New Hampshire, Maine, Connecticut members) Anthem Blue Cross Blue Shield PO Box 533 North Haven, CT 06473

Write “Health Action Plan” in the lower left corner of the envelope. This form must be submitted to Anthem no later than 90 days after the end of your plan period.

* Members allowed to participate in Rewards program are at employer's discretion.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non­HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self­funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

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