Get Rewarded for This Visit!
‘Ohana Healthy Rewards is a program where members can earn rewards for taking care of their health.
Please complete the information below with your provider and then fax a copy to 1-888-965-5932.
First and Last Name: Date of Birth: / /
Address: City:
State: Zip: Name of Clinic/Location:
Clinic Zip: Doctor’s Name (First and Last):
Email Address:
Provider ID: Provider Signature:
Please let us know which service you had by checking the box below: (one health care activity per sheet):
Reward
Health Care Activity* Value
Health Care Activity* Reward Value General
oAnnual Physical Exam $25.00
oDiabetic Blood Test (A1C) $25.00 oMeeting Your Care Provider $15.00 oBreast Cancer Screening $25.00 oCervical Cancer Screening $25.00 oHealth Risk Assessment $10.00 oBehavioral Health Follow Up $25.00 oSubstance Use Initiation $15.00 oSubstance Use Engagement $25.00
oTobacco Cessation $25.00
Prenatal
oPrenatal Care Visit
$25.00 + Merchandise oPostpartum Care Visit $25.00 +
Merchandise
Well-Child
oBirth to 15-Month Well-Child Visit 1 $10.00+
Merchandise oBirth to 15-Month Well-Child Visit 2 $10.00+
Merchandise oBirth to 15-Month Well-Child Visit 3 $10.00+
Merchandise oBirth to 15-Month Well-Child Visit 4 $10.00+
Merchandise oBirth to 15-Month Well-Child Visit 5 $10.00+
Merchandise oBirth to 15-Month Well-Child Visit 6 $10.00+
Merchandise oAnnual Adolescent Visit $25.00
*See back for Health Care Activity criteria
Please select one of the rewards below:
(Default**)
For more reward options, complete your activities by going online to www.ohanahealthplan.com or calling 1-888-846-4262 (TTY: 711) Monday – Friday: 7:45 a.m. to 4:30 p.m. Hawai`i Standard Time Please allow 2-4 weeks for delivery. **This reward will be sent if no choice is made.
Terms and Conditions Target GiftCardTM
The Bullseye Design, Target and Target GiftCard are registered trademarks of Target Brands, Inc. Terms and conditions are applied to gift cards. Target is not a participating partner in or sponsor of this offer.
Health Care Activity Criteria
Population Segment Activity Criteria General
Annual Physical Exam A check-in with your care provider about your overall health.
Diabetic Blood Test (A1C) Complete a diabetic blood test (A1C) for members with diabetes ages 18-75.
Meeting Your Care Provider A visit to establish a relationship with a primary care provider.
Breast Cancer Screening Complete an office visit for breast cancer screening for women ages 50-74.
Cervical Cancer Screening A test to look for changes or detect cervical cancer.
Health Risk Assessment A set of questions to see how healthy you are.
Behavioral Health Follow Up Complete a behavioral health follow up with a mental health practitioner.
Substance Use Initiation Start a treatment program within 14 days of your doctor’s visit to earn a reward.
Substance Use Engagement Complete two or more treatment programs within 34 days of your doctor’s visit to earn a reward.
Tobacco Cessation A Tobacco Cessation program provides resources and tools to help you quit.
Prenatal
Prenatal Care Visit Attend your prenatal care visit(s).
Postpartum Care Visit Attend 1 postpartum care visit 3-8 weeks after the birth of your baby.
Well-Child Birth to 15-Month
Well-Child Visit Children ages 0-15 months are eligible for 6 visits a year (per regular schedule).
Annual Adolescent Visit Children ages 12-21 are eligible for a yearly adolescent health checkup visit.
Walmart Gift Card
For balance inquiry, call 1-888-537-5503 or go to Walmart.com/giftcards or samsclub.com. Use this card at any Walmart store or Sam’s Club in the U.S. or Puerto Rico, or on-line at Vudu, Inc., Wal-Mart.com or Samsclub.com. The balance on this card is a liability of Wal-Mart Stores Arkansas, LLC. This card cannot be redeemed for cash except where required by state law. Lost or stolen cards will not be replaced.
Walmart may refuse to accept this card and to take action, including balance forfeiture, for fraud, abuse or violations of terms. Terms and conditions subject to change without notice. See Walmart.com for complete terms. Treat this card like cash.
Novu LLC is not affiliated with Walmart Stores, Inc., or any of its affiliates. The services, products or activities of Novu LLC are neither endorsed nor sponsored by Walmart Stores, Inc., or any of its affiliates.
See www.walmart.com/giftcardtermsandconditions for complete gift card terms and conditions.
Please note alcohol, tobacco, firearms and lottery tickets cannot be purchased using this Gift Card.
CAD_52863E_Internal Approved 04032020
©WellCare 2020 HI0CADFRM52863E_0220
