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Wellness Incentive Program
Q. What is the Wellness Incentive Program?
A. This program is a wellness initiative in which eligible State Health Plan members who meet certain requirements may receive specific disease-related generic drugs at no cost for 12 months. The diseases that are included in this program are cardiovascular disease, congestive heart failure and diabetes. Diabetic supplies are also covered.
Q. Which conditions are covered under the Wellness Incentive Program?
A. The diseases that are included in the Wellness Incentive Program are: diabetes; cardiovascular disease, which includes coronary artery disease (CAD), hypertension (high blood pressure) and hyperlipidemia (high cholesterol); and congestive heart failure.
Q. When did this program start?
A. PEBA Insurance Benefits began waiving generic copayments for eligible drugs and diabetic supplies on January 1, 2011, for members who qualify for the program.
Q. Why is PEBA Insurance Benefits offering it?
A. PEBA Insurance Benefits is waiving the copayments for these generic drugs and diabetic supplies as part of an effort to encourage subscribers and their covered dependents with diabetes or cardiovascular disease to better manage their conditions. The hope is that this will not only improve the lives of members but will also save the plan money over time.
Q. To which health plans does it apply?
A. It only applies to members for whom the State Health Plan is primary. It does not apply to BlueChoice HealthPlan HMO or Medicare-primary recipients. If a dependent of a Medicare Supplemental Plan subscriber is not eligible for Medicare and is, therefore, covered under the Standard Plan provisions, he may be eligible for the Wellness Incentive Program.
Q. Who can participate?
A. Subscribers and their covered dependents*, whose primary coverage is the State Health Plan are eligible for the Wellness Incentive Program. Retiree, COBRA and survivor subscribers and their covered dependents may also potentially qualify to participate.
*Dependent children are eligible for program if they are diagnosed with diabetes and they are at least 5 years old; otherwise, the dependent must be at least 18 years old.
Q. Are my covered dependents and I eligible if coverage through PEBA Insurance Benefits is not our primary insurance?
A. If you or your covered dependents have other insurance that is primary (pays your claims first, before your insurance through PEBA Insurance Benefits), neither you nor your dependents can participate in this program.
Please note that should you become eligible for Medicare or other coverage as your primary insurance during the 12 months for which you have already qualified for the program, you will still be eligible to receive your medications or diabetic supplies through the end of the 12-month period free of charge. You will not, however, be eligible to requalify for the program.
Q. How are members selected for the program?
A. Members are identified through claims or preauthorizations for one of the qualifying conditions (diabetes, cardiovascular disease or congestive heart failure). Members may already be participating in the BCBSSC Health Management Program.
Members are identified through claims or preauthorizations for one of the qualifying conditions: cardiovascular disease, congestive heart failure or diabetes. They may already participate in the BCBSSC Health Management Program. Members who are identified as having one of the qualifying conditions will receive a letter or phone call from BCBSSC explaining the details of the Wellness Incentive Program, including how to participate in the Health Management Program. A member who thinks he may qualify for the Wellness Incentive Program but has not been notified of his eligibility may call 800-868-2500, select 1 and then extension 49043.
Q. If I decide not to participate in the incentive program, can I change my mind later? If so, what do I do?
A. If you have opted out of the Wellness Incentive Program, you can change your mind and participate by calling BlueCross BlueShield of South Carolina at 803-736-1576 (Greater Columbia area) or 800-868-2520 (toll-free outside the Columbia area).
Q. Is there an application form?
A. No. Members simply follow the instructions outlined in the question below.
Q. How do I qualify?
A. To qualify, you must:
- Participate in the BlueCross BlueShield of S.C Health Management Program. Members who do not participate or opt-out of the program will not be eligible to qualify for free generic drugs or diabetic supplies. For more information on this program, refer to your Insurance Benefits Guide.
- Complete the BCBSSC Health Management Survey specifically related to the condition with which you have been identified. Read this flyer to learn how to get to your assessment.
- Complete a doctor’s office visit.
- Have the appropriate lab test for your condition.
Some participants may receive a letter instructing them to complete some additional requirements to participate.
- You may be asked to annually complete four successful telephone contacts with a health coach.* The first call is the disease-specific related assessment. The next three calls evaluate your progress, address any health concerns or barriers to care and reinforce positive changes. Typically, the time between the first three calls is one month, while the time between the third and fourth call can be slightly longer. Once all four calls are complete, you may be eligible to receive your medications or diabetic supplies. Your health coach can help you determine how you can complete your requirements.
If you did not receive a letter instructing you to complete the additional requirement, call 800-868-2500, select 1 and extension 49043 to speak with a health coach. The health coach can tell you if you must meet the additional requirement.
*Participation in an American Diabetes Association (ADA) or an American Association of Diabetes Educators (AADE)-approved diabetes education class, if approved by the member's physician, or completion of a phase 2 cardiac rehabilitation program prescribed by a physician can replace the four contacts with a health coach.
Q. How will I learn if I qualify for the waiver?
A. You will receive a letter from BlueCross BlueShield of South Carolina saying that you have qualified for the Wellness Incentive Program once all the requirements are met.
Q. I think I may be eligible for the incentive program, but I have not received an invitation letter from BCBSSC. What should I do?
A. BlueCross BlueShield of S.C. will send you a letter saying that you have been identified for the Wellness Incentive Program and the Health Management Program. Members are identified through claims or preauthorizations for one of the qualifying conditions (diabetes, cardiovascular disease or congestive heart failure). If BlueCross has not contacted you, and you think you might be eligible for the program, call 800-868-2500, select 1 and extension 49043.
Q. What generic drugs are included in the Wellness Incentive Program?
A. The Wellness Incentive Program offers generic versions of covered drugs in these classes:
The drug must be on the formulary as established by the prescription drug program. A formulary is a list of specific drugs covered by a health insurance program. The list is subject to change, so please check the Express Scripts website to verify if a prescription qualifies for the program.
To check the price of your prescription drug, login to the Express Scripts website and click "Price a medication" from the left menu. Follow the prompts to find out what the prescription will cost you. You must have qualified for the Wellness Incentive Program before the eligible prescription will be shown with $0 copay.
Please note: Insulin is not a generic drug and therefore copayments for it are not waived as part of the Wellness Incentive Program.
You must use a network pharmacy or the mail-order pharmacy to receive the free generic drugs.
Q. I'm enrolled in the Savings Plan. Will the cost of the generic drugs and/or diabetic supplies be applied to my deductible?
A. No. Since eligible generic drugs and supplies are provided at no cost in the Savings Plan, they will not be applied to the deductible.
Q. What if I take a generic drug that has to be preauthorized?
A. Even though the copayment for your drug may be waived, you may still have to preauthorize it.
Q. What will happen if I do not complete all the requirements for the waiver?
A. You will not qualify for the Wellness Incentive Program.
Q. How can I complete the assessment?
A. Click on the “Links” tab on the PEBA Insurance Benefits website and select "Medical (BlueCross BlueShield of South Carolina."
After you log in to “My Heath Toolkit,” click on “Personal Health Record.” A new window will appear. Then click on My Assessments highlighted in yellow within My Activity Center and answer the questions. Once you have completed all questions, click on Save and Complete.
Members may also take the assessment over the phone. To complete the assessment over the phone, call 800-868-2500, select 1 and extension 49043. You take the condition-specific online assessment once.
To requalify for the Wellness Incentive Program in subsequent years, you must complete your online Personal Health Assessment (PHA). You can access your PHA the same way by selecting "My Health Toolkit" from either the PEBA Insurance Benefits or BCBSSC websites.
Q. Which lab tests are needed for diabetes?
A. The Hemoglobin A1C test, drawn twice a year, is the required lab for those who have diabetes. The tests must be at least three months apart.
Q. Which lab tests are needed for cardiovascular disease (CAD, hypertension or hyperlipidemia) or congestive heart failure?
A. If you are identified for the program due to having coronary artery disease, hypertension or hyperlipidemia, you will need a full lipid panel every 12 months that measures the following in order to qualify for the program:
- Triglycerides
- LDL (low-density lipoprotein)
- HDL (high-density lipoprotein)
- Total cholesterol
The tests above are included in Prevention Partners’ Preventive Workplace Screening, which is available for only $15. For more information on how to have a Preventive Workplace Screening at your work place, talk to your benefits administrator or Workplace Wellness Coordinator.
Q. Must the annual doctor's office visit be to a medical doctor (MD)?
A. A visit to a Doctor of Osteopathy (DO), a Physician's Assistant (PA), an Advanced Practice Registered Nurse (APRN) or a Medical Doctor (MD) qualifies as an annual doctor's visit.
Q. Which education programs can replace the four conversations with a health coach?
A. The four conversations with a health coach can be replaced by:
- A phase 2 cardiac rehabilitation program as prescribed by a physician.
- An ADA (American Diabetes Association) or AADE (American Association of Diabetes Educators) approved diabetes education class:
- Accredited Programs – (AADE)
- Recognized Education Programs– DiabetesPro –(ADA)
- Other condition-appropriate education programs:
- These programs must be certified by the ADA or the American Heart Association.
- Members must send proof they completed such a program to BCBSSC. Documentation of your participation in a class should be sent to your health coach at 803-870-8600 or mailed to BCBSSC at the address below:
BCBSSC
I-20 at Alpine Rd., AX-745
Columbia, SC 29219
Attn: Jane Vaughan
Please be sure that the documentation for education programs includes your BIN or other identifying information so you will receive credit.
Q. Will the cost of the classes or the phase 2 cardiac rehabilitation program be covered by my health insurance?
A. A phase 2 cardiac rehabilitation program is a covered service, subject to the annual deductible, a per-occurrence deductible and coinsurance under the Standard Plan and subject to the annual deductible under the Savings Plan. You or your provider must call Medi-Call for preauthorization of this program.
Other classes and education programs are not covered.
Q. What documentation is required to show I've completed a class or a rehabilitation program and to whom should I send it?
A. Verification for completing a phase 2 cardiac rehabilitation program is automatic. You do not need to submit anything.
Documentation of your participation in a class should be sent to your health coach at 803-870-8600 or mailed to:
BCBSSC
I-20 at Alpine Rd., AX-745
Columbia, SC 29219
Attn: Jane Vaughan
Please be sure that the documentation for education programs includes your BIN or other identifying information so you will receive credit.
Q. When can a member begin completing the requirements for the Wellness Incentive Program?
A. You can begin at any time. Once you have completed the requirements and have been qualified by BCBSSC, your eligibility for the Wellness Incentive Program will start the first day of the following month.
Q. When will the Wellness Incentive Program begin for me?
A. The program will begin the first day of the month after you complete the qualifications. For the program to continue after 12 months, you must requalify. To requalify, you must complete your online Personal Health Assessment (PHA).
Q. What if I qualified for the program beginning on March 1? Will my waiver still end on December 31?
A. Your eligibility in the Wellness Incentive Program will last for a full 12 months once you have qualified. You will receive a letter three months before the end of the 12-month period telling you how to requalify for another 12 months in the program.
Q. What happens if I qualify for the program and am taking one drug and then, a few months later, get a prescription for another drug covered under the program. Will I get that drug free for 12 months from the date I began taking it?
A. Your waiver will still end 12 months from the date you first qualified for the program. For example: If you use a generic drug for high cholesterol and your start date is January 1, and then, on April 1, you are prescribed another generic blood pressure drug, your program will still end December 31, 12 months from your start date.
Q. If I qualify, how long will my copayments for generic drugs be waived?
A. Your copayments will be waived for 12 months. If you become eligible for Medicare or other coverage as your primary insurance during the 12-month waiver, the waiver will continue through the end of the 12-month period. However, you will not be eligible to requalify or to extend the waiver if you continue to have another primary insurance carrier.
Q. How will I know my Wellness Incentive Program is expiring?
A. BCBSSC will send you a letter 90 days before your program ends with instructions on how to requalify.
Q. How do I requalify for the waiver?
A. Before your initial 12-month waiver ends, you must requalify to extend the waiver for another 12-month period. To requalify, you must:
- Continue to participate in the BlueCross BlueShield of S.C. Health Management program.
- Take your online Personal Health Assessment (PHA) on the BlueCross BlueShield of S.C. website. Read this flyer to learn how to take your follow-up assessment.
- Re-do the lab work, office visits and health coaching calls specific to your disease condition for the upcoming year.
Q. When can I start requalifying for the waiver?
A. You can start requalifying anytime during your current program period, or after it expires. You may wish to requalify for the Wellness Incentive Program while your current program is still in force. If you do that, there may be no break in the waiver of copayments for your generic prescriptions or diabetes supplies.
After you complete the requirements for continuing the waiver and have been requalified by BCBSSC, the next 12-month waiver period will start the first day of the following month.
Q. May my spouse or children qualify for the waiver?
A. As long as your spouse or children's primary coverage is the State Health Plan, they would follow the same procedures specific to their disease to qualify. Call you health coach to verify your child's eligibility.
Children age 5 and older are eligible if they have been diagnosed with diabetes. For all other conditions, participants must be 18.
Q. I still have questions about the Wellness Incentive Program. Who should I call?
A.
- For general information about the Wellness Incentive Program call BCBSSC Customer Service at 800-868-2520. If you think you qualify for the Wellness Incentive Program and have received a Health Management Program letter, or if you need to reach a health coach, call 800-868-2500, select 1 and then extension 49043.
- For questions about your prescription drugs, call Express Scripts at 800-711-3450.
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