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Looking for motivation to exercise?The Healthy LifestylesSM fitness program will reimburse you $150 for working out regularly.Four easy steps1. Join an approved fitness center. Choose a full-service fitness center that includes amenities for continuous cardiovascular, flexibility, and resistance training. You may also submit activity for virtual sessions through digital subscriptions or apps.2. Exercise at your fitness center regularly. Work out at your approved fitness center or via virtual sessions through a digital subscription or app at least 120 times during a 365-day period. 3. Record your workouts. After you complete 120 workouts, you can request a reimbursement. Your logged workouts must be at least eight hours apart.4. Submit your documentation and request reimbursement. Log in to ibx.com/reimbursements and upload copies of the following documentation:• Proof of payment • Record of your workoutsOnce all your documentation is submitted, you can request your reimbursement to be paid by direct deposit or American Express rewards card.*Achieve Well-beingOur personalized online tools and resources help you achieve what’s important in a way that’s simple, easy, and fun. Visit ibx.com to get started today.* Please note that American Express charges a fee of $4.00 plus three percent of reimbursement amount.Start your well-being journey today! Visit ibx.com or download the IBX mobile app. Get back!Complete 120 workouts at an approved fitness center
Fitness Program guidelinesEligible membersParticipants must be 18 or older.Selecting an approved fitness centerTo be eligible for the fitness center reimbursement, you must choose a full-service fitness center that offers a variety of cardiovascular, flexibility, and resistance training in a supervised setting.Eligible fitness centersEligible full-service fitness centers generally feature most of the following amenities:• Group exercise classes (e.g. aerobics, spinning, body sculpting, kickboxing)• Resistance training equipment (e.g., weight machines)• Free weights• Cardiovascular training equipment (e.g., treadmills, stationary bicycles, elliptical trainers)• Pool for swimming laps• Track for running/walkingIneligible fitness centersMembership at athletic clubs that feature a single competitive or recreational sports activity are not eligible for reimbursement, including programs and facilities focused on:• Tennis/squash/racquetball• Basketball• Golf• Pilates/yoga class• Martial arts/ karate class• Sports leagues• Recreational swim clubs• Dance instruction• Outdoor “boot camp” style program• Sculling/style program rowing• Chiropractic servicesLifetime fitness center membershipsIf you purchase a lifetime membership at a fitness center, you are eligible to receive a reimbursement of up to $150 of the membership fees paid once per calendar year as long as the required number of workouts are completed.Family fitness center membershipsFamily memberships are subject to the following conditions:• Each family member who requests the reimbursement must be listed on the membership contract.• Each family member who requests the reimbursement must individually participate in the Fitness Program and fulfill all Fitness Program reimbursement requirements. Each eligible family member may receive reimbursement of up to $150 of his or her portion of the total annual membership fees once per calendar year.Example:• Family fitness center annual contract fee is $700.• Four family members are listed on the family fitness facility contract.• Two family members are 18 or older and, therefore, are eligible for reimbursement.• $700 ÷ 2 = $350 (each eligible family member’s portion of the total contract fee).In this example, if the two eligible family members complete all Fitness Program requirements, each will receive up to $150 (his or her portion of the family fitness facility annual contract fee). If only one eligible member completes all Fitness Program requirements, the family member will receive up to $150 (his or her portion of the family fitness facility annual contract fee).Workouts outside of a fitness facilityActivity and membership costs for virtual sessions through digital subscriptions or apps may be submitted in addition to or in place of workouts within a fitness center. Please note that the 120 workouts requirement applies to activity taking place outside of a fitness facility, and this requirement must be completed in order to earn reimbursement.
Reimbursement rules and requirements• You must complete 120 workouts during a 365-day Fitness Program period. However, the 365-day time period does not need to be within the same calendar year as the reimbursement. For example, you could get a reimbursement paid out in January 2019 for 120 workouts documented in 2018.• You must have coverage with Independence at the time of your request for reimbursement.• You are only eligible for one reimbursement per program, per calendar year.• Dependents must be at least 18 years old to be eligible for reimbursement.• Logging in for another member at a fitness center is prohibited.• Falsification of information in order to receive your reimbursement is strictly prohibited.How to record your workouts• Record workouts using the logbook: To record workouts using the logbook on page 4, ask a fitness center representative to sign and date the logbook each time you work out. You may also use the logbook to record your workouts when you visit a fitness center other than your primary fitness center (e.g., when you work out while traveling or vacationing out of town).• Record workouts using a fitness center’s computer printouts: You may choose to use your fitness center’s computer printout as your primary method of logging workouts. However, keep in mind that Independence cannot assume any responsibility for the reliability of fitness center computer systems. For this reason, if you select a fitness center computer printout as your primary method of logging workouts, you also accept the risk that all your workouts may not be credited.Other important information• Independence does not guarantee the solvency of any fitness center and, therefore, has no liability should a fitness center close.• For members other than those enrolled in a Medicare Advantage plan, Healthy Lifestyles programs are value-added. They are not part of the health care benefits you have purchased and, therefore, are subject to change without notice.• At Independence, we encourage all of our members to adopt and maintain a regular fitness program. However, if you are 40 or older, overweight, have a history of high blood pressure or heart disease, or have any other health concerns related to exercise, you are encouraged to consult your doctor before beginning any exercise program.• If you are unable to complete workouts due to a medical procedure, please call 1-800-590-8880.Questions?Call Healthy Lifestyles at
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Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.17863 2014- 19 87 (10/14) FITNESSDateFitness facility representative signatureWorkout time61.❑ am❑ pm62.❑ am❑ pm63.❑ am❑ pm64.❑ am❑ pm65.❑ am❑ pm66.❑ am❑ pm67.❑ am❑ pm68.❑ am❑ pm69.❑ am❑ pm70.❑ am❑ pm71.❑ am❑ pm72.❑ am❑ pm73.❑ am❑ pm74.❑ am❑ pm75.❑ am❑ pm76.❑ am❑ pm77.❑ am❑ pm78.❑ am❑ pm79.❑ am❑ pm80.❑ am❑ pm81.❑ am❑ pm82.❑ am❑ pm83.❑ am❑ pm84.❑ am❑ pm85.❑ am❑ pm86.❑ am❑ pm87.❑ am❑ pm88.❑ am❑ pm89.❑ am❑ pm90.❑ am❑ pmDateFitness facility representative signatureWorkout time91.❑ am❑ pm92.❑ am❑ pm93.❑ am❑ pm94.❑ am❑ pm95.❑ am❑ pm96.❑ am❑ pm97.❑ am❑ pm98.❑ am❑ pm99.❑ am❑ pm100.❑ am❑ pm101.❑ am❑ pm102.❑ am❑ pm103.❑ am❑ pm104.❑ am❑ pm105.❑ am❑ pm106.❑ am❑ pm107.❑ am❑ pm108.❑ am❑ pm109.❑ am❑ pm110 .❑ am❑ pm111.❑ am❑ pm112 .❑ am❑ pm113 .❑ am❑ pm114.❑ am❑ pm115.❑ am❑ pm116 .❑ am❑ pm117.❑ am❑ pm118.❑ am❑ pm119.❑ am❑ pm120.❑ am❑ pm1133286 (08/20)Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.
Y0041_HM_17_47643 Accepted 10/14/2016 Taglines as of 10/14/2016 Language Assistance Services Spanish: ATENCIÓN: Si habla español, cuenta con servicios de asistencia en idiomas disponibles de forma gratuita para usted. Llame al 1-800-275-2583 (TTY: 711). Chinese: 注意：如果您讲中文，您可以得到免费的语言协助服务。致电 1-800-275-2583。 Korean: 안내사항: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-275-2583 번으로 전화하십시오. Portuguese: ATENÇÃO: se você fala português, encontram-se disponíveis serviços gratuitos de assistência ao idioma. Ligue para 1-800-275-2583. Gujarati: : , : . 1-800-275-2583 કોલ કરો. Vietnamese: LU Ý: Nu bn nói ting Vit, chúng tôi s cung cp dch v h tr ngôn ng min phí cho bn. Hãy gi 1-800-275-2583. Russian: : -, . .: 1-800-275-2583. Polish UWAGA: Jeeli mówisz po polsku, moesz skorzysta z bezpatnej pomocy jzykowej. Zadzwo pod numer 1-800-275-2583. Italian: ATTENZIONE: Se lei parla italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-275-2583. Arabic: : . 1-800-275-2583. French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-275-2583. Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, magagamit mo ang mga serbisyo na tulong sa wika nang walang bayad. Tumawag sa 1-800-275-2583. French: ATTENTION: Si vous parlez français, des services d'aide linguistique-vous sont proposés gratuitement. Appelez le 1-800-275-2583. Pennsylvania Dutch: BASS UFF: Wann du Pennsylvania Deitsch schwetzscht, kannscht du Hilf griege in dei eegni Schprooch unni as es dich ennich eppes koschte zellt. Ruf die Nummer 1-800-275-2583. Hindi: : 1-800-275-2583 German: ACHTUNG: Wenn Sie Deutsch sprechen, können Sie kostenlos sprachliche Unterstützung anfordern. Wählen Sie 1-800-275-2583. Japanese: 備考：母国語が日本語の方は、言語アシスタンスサービス（無料）をご利用いただけます。 1-800-275-2583へお電話ください。 Persian (Farsi): : . 1-800-275-2583 . Navajo: D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh. H0d77lnih koj8’ 1-800-275-2583. Urdu: : .1-800-275-2583 Mon-Khmer, Cambodian:: - 1-800-275-2583
Y0041_HM_17_47643 Accepted 10/14/2016 Taglines as of 10/14/2016 Discrimination is Against the Law This Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. This Plan provides: Free aids and services to people with disabilities to communicate effectively with us, such as: qualified sign language interpreters, and written information in other formats (large print, audio, accessible electronic formats, other formats). Free language services to people whose primary language is not English, such as: qualified interpreters and information written in other languages. If you need these services, contact our Civil Rights Coordinator. If you believe that This Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator. You can file a grievance in the following ways: In person or by mail: ATTN: Civil Rights Coordinator, 1901 Market Street, Philadelphia, PA 19103, By phone: 1-888-377-3933 (TTY: 711) By fax: 215-761-0245, By email: civilrightscoordinator@1901market.com. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.