Oxford Gym Reimbursement – Fill Out and Use This PDF

Healthier members are happier members.

Starting or staying with an exercise routine isn’t always easy. To help you stay motivated and achieve your itness goals, we provide reimbursement toward itness center membership fees.1 You can get reimbursed for going to the gym an average of two-to-three times per week. We know that staying with an exercise routine isn’t always easy, and this can help you stay motivated and healthy.

Note: his reimbursement is not available to all Oxford plan members, including members of any Connecticut plan, and some New York and New Jersey plans. Please refer to your Certiicate of Coverage, Summary Plan Description or other governing member document that applies to your plan for beneit availability.

It’s easy. First, select a gym.

To receive reimbursement, you must participate in a gym and/or program that promotes cardiovascular wellness. (Memberships in sports clubs, country clubs, weight loss clinics, spas or other similar facilities are not eligible.) For a gym to be considered eligible, it must provide at least two pieces of equipment or activities that promote cardiovascular wellness from the following list:

How much can you get reimbursed?

Please check your beneits documents or check with your beneits administrator to determine how much you (and your spouse or domestic partner) may be reimbursed.2

he reimbursement period begins on the date of your initial visit to the gym and ends six months from that date. Subsequent reimbursement periods begin one day after your previous reimbursement period ended.3

You should follow the steps below to receive reimbursement for your fitness participation:

1. Visit the gym – You must complete a minimum of 50 visits per six-month period. Reimbursements will not be issued until six months have passed, even if 50 visits are completed sooner than six months.

2. Collect paperwork – You need to collect three things: a copy of your current gym bill, showing the monthly cost of your membership; proof of payment for each of the six months you are submitting for reimbursement (i.e., credit card statement, payroll deduction, automatic bank withdrawal, etc.);4 and a copy of the brochure that outlines the services the gym ofers.

3. Complete the form – Fill out and submit a Gym Reimbursement Form, which is shown on the reverse side of this page. Remember to provide the dates of your gym visits completed within the six-month period for which you are making a claim. Also, a representative from your gym must sign the form. You can get extra forms from your beneits administrator, from our website oxfordhealth. com or by calling Customer Service at the telephone number on your health plan ID card.

4. Mail everything – he Gym Reimbursement Form, along with a copy of your current gym bill, proof of payment and a copy of the gym’s brochure, should be submitted within six months (180 days) to the following address:

Oxford Gym Reimbursement

P.O. Box 29130

Hot Springs, AR 71903

Call the telephone number on your health plan ID card

Important: Please complete the form in its entirety, or the processing of your claim may be delayed or denied. Please complete one form per member, for each six-month period for which you are making a claim.