Skip to main content
855-442-9940

Wellness Reimbursement

Please fill out this form to request reimbursement for your wellness activities.

man with bike
SelectHealth Advantage (HMO) Wellness Reimbursement

Please allow 2-3 weeks for wellness reimbursements to be processed.



*
*  
* Example: For (801)123-4567 enter 8011234567 (numbers only)  
*
* * *
 



$*
* DD/MM/YYYY





Total attached files should not be larger than 15 MB.



The wellness activities listed below are eligible for annual reimbursement up to a combined total of $20 times the number of months you will be covered during the year (for example, a full calendar year of membership—12 months—qualifies for $240 reimbursement for that year). Please attach a receipt or other proof of payment (like a bank statement) with this completed form. We cannot reimburse you without proof of payment (see Chapter 4 of your Evidence of Coverage for additional details).



Gym or Fitness Center

This includes monthly or annual membership fees to any commercial or community gym or fitness facility, or fees for individual physical activity classes (e.g., yoga or boot camp). Since SelectHealth Advantage has no formal contract or agreement with any gym or fitness facility, if an additional fee for orientation to the facility or equipment is charged, the fee is eligible for reimbursement as well. This benefit does not include reimbursement for personal fitness equipment or apparel.

Note: For reimbursement of an annual membership fee, for new SelectHealth Advantage members (enrolled after January 1), we will reimburse a maximum of $20 multiplied by the number of remaining months in the calendar year. For current members (enrolled for January 1 coverage), the maximum will be $20 multiplied by 12, or $240.

*
* Example: For (801)123-4567 enter 8011234567 (numbers only)
 

Weight Loss Program

This includes approved weight loss programs such as Intermountain’s The Weigh to Health, Weight Watchers, Jenny Craig, or programs administered by an in-network hospital or clinic Other formal weight loss programs may be approved by SelectHealth for coverage under this benefit if they are provided by a certified health educator or qualified licensed health professional.

*
*
* * *
* Example: For (801)123-4567 enter 8011234567 (numbers only)
 

Health Education

This includes approved health education classes and activities. Other formal health education classes may be approved by SelectHealth for coverage under this benefit if they are provided by a certified health educator or qualified licensed health professional. They must also be composed of interactive sessions that primarily provide health information, encourage adoption of healthy behaviors, build skills to enhance self-care capabilities, and align with the overall goal to improve participants’ health. The benefit may include group sessions in which the educator provides information or skills instruction, one-on-one instruction sessions, and/or interactive Web and/or telephone-based coaching to reinforce what an enrollee learned in a group or individual session. This benefit does not cover alternative or holistic education services.

* * Example: For (801)123-4567 enter 8011234567 (numbers only)  
*
*
* * *
 

If you have questions regarding this reimbursement form or process, please call Member Services tollfree at 855-442-9900 during the following dates and times:

  • October 1 to February 14: Weekdays 7:00 a.m. to 8:00 p.m., Saturday and Sunday 8:00 a.m. to 8:00 p.m.
  • February 15 to September 30: Weekdays 7:00 a.m. to 8:00 p.m., Saturday 9:00 a.m. to 3:00 p.m., closed Sunday.

Outside of these hours of operation, please leave a message. Your call will be returned within one business day. TTY users should call 800-346-4128 (in Utah), 800-377-3529 (in Idaho), or 711.


You are now leaving the SelectHealth Medicare website.


Stay Continue

The Annual Election Period, or Open Enrollment for Medicare Advantage, begins October 15. Please come back to enroll on or after that date. If you are new to Medicare or qualify for another Special Enrollment Period, click continue.


Cancel Continue

You are now leaving the SelectHealth Medicare website.


Stay Continue

Thanks for reaching out.

Someone will be in contact with you soon.

Close

For 2016, we have only been able to establish in-network provider contracts for this new hearing aid benefit in these two plan regions. We hope to be able to offer the benefit in other plan regions in the future.


Close

Thank you, your reimbursement request has been received. Please allow 2-3 weeks for wellness reimbursements to be processed.


Close

Thank you, your plan change request has been received.


Close
Close