Healthy Blue Living℠ BCN Qualification Form
Who is this for?
If you're a Healthy Blue Living or Healthy Blue Living Rewards 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, you and your doctor need to fill out this form within 90 days after you enroll in or renew the Healthy Blue Living or Healthy Blue Living Rewards℠ plan.
This applies to everyone covered by the plan who has to meet the requirements for intermediate or enhanced benefits.
Access the form here: Healthy Blue Living BCN Qualification Form (PDF)
You’ll need a printer to print the form.
How to read the qualification form
The form uses a simple A, B, C grading system:
A = You meet 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.
The grades you need to earn for your benefit level are different for each plan.
For Healthy Blue Living:
- If you and your covered spouse earn all As or Bs, you’ll get enhanced benefits.
- If you or your covered spouse get a C on any health measure, everyone is moved to standard benefit level.
For Healthy Blue Living Rewards:
- If you and your covered spouse earn all As, the entire contract gets enhanced benefits.
- If you or your covered spouse earn a combination of As or Bs, you’ll get intermediate benefits.
- Earning one or more Cs on any of the health measures will move the entire contract to the standard benefit level.