Disease Management Incentive Program

Thank you for choosing Sentara Health Plans for your health coverage through the Commonwealth of Virginia or The Local Choice employers.

You are applying for the Disease Management Incentive Program. The information below is used to enroll you or a covered family member in the Incentive Program. Each family member who has a condition will need to complete this online application.

Program participation is voluntary and is for those members diagnosed with asthma/chronic obstructive pulmonary disease, diabetes or hypertension.

Completion of this application is voluntary. You will not be denied health plan coverage or treatment based on information provided.

Please review and acknowledge the following statement before proceeding with the application:

I understand that participation in the Disease Management Incentive Program is voluntary and that continued participation requires completion of certain health activities: speaking with a health coach once per year, an annual wellness exam with my treating healthcare provider and at least one physician visit or medication refill for my diagnosed condition. I understand that Sentara Health Plans will use claims data review to validate the required activities. I understand that I must apply or re-apply for program participation in the designated timeline of application according to my plan benefit year.

Member Information

Note: Asterisk * indicates a required field

Form

First Name*

Last Name*

Date of Birth*

Birth Month

Birth Day

Birth Year

Phone Number*

Email Address*

Mailing Address 1*

Mailing Address 2

City*

State*

ZIP Code*

Member ID (if known) Secondary Member ID*

Box 1: Enter the first 7 numbers before the asterisk * on your member ID card.

Box 2: Enter the last 2 numbers after the asterisk * on your member ID card.

Primary Care Physician*

Physician's Office Phone Number

Condition (select all that apply)*

Asthma Chronic Obstructive Pulmonary Disease (COPD) High Blood Pressure or Hypertension Diabetes

Are you taking medications for your condition?* Yes No

If yes, what is name of the medication?

As a new Sentara Health Plans enrollee, I understand that Sentara Health Plans would like to collect some limited information about my health conditions in order to enroll in the Disease Management Incentive Program.

I authorize Sentara Health Plans to share the information collected about my health or the health of my dependents with the Sentara Health Plans care team for purposes of enrolling in the Disease Management Incentive Program.

Any information received by Sentara Health Plans is subject to restrictions on disclosure to others as set forth under state and Federal laws.

I understand that participation in the Disease Management Incentive Program is voluntary and that continued participation requires completion of certain health activities: speaking with a health coach once per year, an annual wellness exam with my treating healthcare provider and at least one physician visit or medication refill for my diagnosed condition. I understand that Sentara Health Plans will use claims data review to validate the required activities.

I understand that this application must be submitted by the timeframe necessary according to my plan year in order to be considered for the full Incentive Program benefits.

Electronic Signature of Applicant*

Today's Date: 6/16/2025

© Sentara Health Plans 2025, 1300 Sentara Park, Virginia Beach, VA 23464

Sentara Health Plans is the trade name for Sentara Health Plans, Sentara Health Insurance Company, Sentara Health Administration, Inc., and Sentara Behavioral Health Services, Inc. Health Maintenance Organization (HMO) products, and Point-of-Service (POS) products are issued and underwritten by Sentara Health Plans. Preferred Provider Organization (PPO) products are issued and underwritten by Sentara Health Insurance Company. Sentara Health Administration, Inc. provides administrative services to group and individual health plans but does not underwrite benefits. All plans have benefit exclusions and limitations and terms under which the policy may be continued in force or discontinued. Medicare products are administered under an agreement with Sentara Health Plans and the Centers for Medicare and Medicaid Services (CMS). Medicaid and FAMIS products are administered under an agreement with Sentara Health Plans and the Virginia Department of Medical Assistance Services (DMAS).