Healthy Blue Living℠ plans BCN Qualification Form
Who is this for?
If you're a Healthy Blue Living plan member, use this form if you've just enrolled or renewed within the last 90 days.
If you want to get lower deductibles and copays, your doctor needs to electronically submit this form within 90 days after you enroll in or renew the Healthy Blue Living plan.
This applies to only the contract holder of the plan.
Access the form here: Healthy Blue Living BCN Qualification Form (PDF)
It's a good idea to print a copy and take it with you to your appointment as a reminder for your doctor.
How to read the qualification form
The form uses a simple A, B, C grading system:
A = You've met the health target
B = You have a health condition that may not be controlled, but you are actively participating in treatment to improve the condition.
C = You're not meeting the wellness target, and you haven’t committed to treatment to improve your condition.
For Healthy Blue Living:
- If the enrollee earns all A's or B's and completes all other plan requirements, they'll earn everyone on their contract the enhanced level for the entire plan year.
- If the enrollee gets a C on any health measure, everyone on their contract moves to the standard level.