| BENEFIT TYPE | IN NETWORK BENEFIT |
|---|
| Referrals | ||
| Referrals | No | |
| PCP Required | ||
| PCP Required | Yes | |
| Annual Medical Deductible | ||
| Annual Medical Deductible | No | |
| Maximum Out-of-Pocket Responsibility | ||
| Maximum Out-of-Pocket Responsibility | $0, you will have no cost sharing responsibility for services. | |
| Hospital Care | ||
| Hospital Care | Inpatient Outpatient |
|
| Doctor Visits | ||
| Doctor Visits | $0 Copay Authorization rules may apply. |
|
| Emergency Care | ||
| Emergency Care | $0 Copay
Coverage is limited to $60,000 worldwide when you are temporarily outside of the United States and its territories. |
|
| Urgently Needed Services | ||
| Urgently Needed Services | $0 Copay
Coverage is limited to $60,000 worldwide when you are temporarily outside of the United States and its territories. |
|
| Diagnostic Services/ Labs/ Imaging | ||
| Diagnostic Services/ Labs/ Imaging | $0 Copay
Authorization rules may apply. Covers
|
|
| Hearing Services | ||
| Hearing Services | $0 Copay
Covered for services rendered beyond Medicare Part B limits. |
|
| Dental Services | ||
| Dental Services | $0 Copay
|
|
| Vision Services | ||
| Vision Services | $0 Copay Covered services include:
Optometrist services and optical appliances must be obtained at a participating Davis Vision Provider. |
|
| Mental Health Services | ||
| Mental Health Services | In-network $0 Copay |
|
| Skilled Nursing Facility (SNF) | ||
| Skilled Nursing Facility (SNF) | $0 Copay
Authorization rules may apply. Covers Nursing Facility services and Nursing Facility. |
|
| Ambulance | ||
| Ambulance | $0 Copay
Authorization rules may apply. |
|
| Prescription Drug Coverage | ||
| Prescription Drug Coverage | $0 Copay , Coinsurance , and Deductible for all covered prescription drugs | |
| Over-the-Counter Personal Health Items | ||
| Over-the-Counter Personal Health Items | OTC (Over-the-Counter) Benefit Card
Every three (3) months you will receive a $375 credit (up to $1,500 annually) that will allow you to purchase personal health and food items without a prescription from our participating retailers. Examples of these personal items are first aid kits, folding canes, denture creams and more. The quarterly credit will not carry over from quarter to quarter or from year to year. All orders must be placed using the plan’s approved OTC Benefit Card at participating retailers or online at NationsOTC.com. *Eligibility criteria applies for Healthy Foods. OTC (Over-the-Counter) CatalogEvery three (3) months you will receive a $250 credit (up to $1,000 annually) that will allow you to purchase personal health items without a prescription from our OTC catalog. Examples of these personal items are first aid kits, folding canes, denture creams and more. The quarterly credit will not carry over from quarter to quarter or from year to year. All orders must be placed using the plan’s approved vendor and all orders will be delivered through the mail. Orders can be placed through the phone at 1-855-345-4759 and online at HorizonBlueOTC.com. |
|
| Fitness Program | ||
| Fitness Program | The no-cost Silver&Fit® Program
|
|
| Foot Care (podiatry services) | ||
| Foot Care (podiatry services) | $0 Copay
Covers routine exams and medically necessary podiatric services, as well as therapeutic shoes or inserts for those with severe diabetic foot disease, and exams to fit those shoes or inserts. |
|
| Home Health Care | ||
| Home Health Care | $0 Copay
Authorization rules may apply. |
|
| Hospice | ||
| Hospice | $0 Copay
Authorization rules may apply. |
|
| Nurse Line | ||
| Nurse Line | Enables you to speak with a registered nurse, toll free 24 hours a day to assist with health-related questions and concerns. Please call 1-800-711-5952 to contact the 24/7 Nurse Line. | |
| Outpatient Surgery | ||
| Outpatient Surgery | $0 Copay
Authorization rules may apply. |
|
| Telehealth | ||
| Telehealth | $0 Copay
Horizon CareOnline℠: is a telemedicine service that allows members to see a licensed, board-certified CareOnline Network doctor without an appointment via phone, video or chat, seven days a week, using a mobile device or web-enabled computer, for urgently needed services and behavioral health. |
|
| Nursing Facility Care | ||
| Nursing Facility Care | $0 Copay
Authorization rules may apply. |
|
| Personal Care Assistance Services | ||
| Personal Care Assistance Services | $0 Copay
|
|
| Post Hospital Discharge Meals - Home Delivered | ||
| Post Hospital Discharge Meals - Home Delivered | After an inpatient hospital discharge to your home, you may be eligible to receive up to 28 nutritious meals over a 14 day period (2 meals per day). Meals must be coordinated by your Care Manager and must be consistent with the established treatment of your illness. | |
Prescription Drug List (Formulary)
Find Medicines Included Here:
https://www.myprime.com/v/HBCBSNJ/MEDICARE_D/NJDSNPHMO/en/medicines/find-medicine.html
The Drug List includes the drugs covered under Medicare Part D. In addition to the drugs covered by Medicare, some prescription drugs are covered for you under your Medicaid benefits. Please refer to the Medicaid wrap covered drug list found below. This includes additional over-the-counter products that can be obtained at your pharmacy with a prescription written by your doctor.
Please refer to our Formulary below for Horizon NJ TotalCare (HMO D-SNP). This is a list of covered drugs selected by Horizon in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Horizon NJ TotalCare (HMO D-SNP) will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Horizon NJ TotalCare (HMO D-SNP) network pharmacy, and other plan rules are followed. Horizon may immediately substitute new generic drugs and update this formulary accordingly.
Medicare Part D Transition Policy
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 31-day transition supply, consistent with the dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
A transition supply will also be available to you if you should have a change in your treatment setting, such as going from a hospital to home care.
Coverage Determination and Redetermination
For details about what we mean by Part D drugs, the List of Covered Drugs (Formulary) and rules and restrictions on coverage see Chapter 5 of your Evidence of Coverage ("Using the plan’s coverage for your Part D prescription drugs")
https://www.myprime.com/v/HBCBSNJ/MEDICARE_D/NJDSNPHMO/en/forms/coverage-determination.htmlSee forms below to find out more information on the Horizon Blue Cross Blue Shield of New Jersey prescription drug coverage Determination and Redetermination process.
You may also ask us for a coverage determination or appeal by phone at 1-800-391-1906, (TTY 771), 24 hours a day, 7 days a week.
Forms may be sent via postal mail at:
-
Horizon Blue Cross Blue Shield of New Jersey
Attn: Medicare D Clinical Review
2900 Ames Crossing Road Eagan, MN 55121
Or via fax at 1-800-693-6703
You can also file grievances, organizational/coverage determinations or appeals with Medicare directly. You can go directly to their website by clicking here or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048
Eligibility Information & Enrollment Instructions
You are eligible for membership in our Plan as long as:
You have both Medicare Part A and Medicare Part B
-- and -- you live in our geographic service area,
-- and -- you are a United States citizen or are lawfully present in the United States,
-- and -- you do not have End-Stage Renal Disease (ESRD), with limited exceptions, such as if you develop ESRD when you are already a member of a plan that we offer, or you were a member of a different plan that was terminated,
-- and -- you meet the special eligibility requirements described below.
Special eligibility requirements for our Plan
Our Plan is designed to meet the needs of people who receive certain Medicaid benefits. (Medicaid is a joint Federal and state government program that helps with medical costs for certain people with limited incomes and resources.) To be eligible for our Plan you must be eligible for Medicare and Full Medicaid Benefits.
Please note: If you lose your Medicaid eligibility but can reasonably be expected to regain eligibility within 60 days (2 full calendar months), then you are still eligible for membership in our Plan.
Medicare beneficiaries may also enroll through the CMS Medicare Online Enrollment Center located at medicare.gov.
ENROLLMENT INSTRUCTIONS:
- Download and print the Enrollment Form in the "Enrollment Form" section. Please complete the form, writing as clearly as you can. The most common errors are from hard-to-read handwriting. Carefully print your answers in the boxes provided.
- Have this important information available:
- Your Medicare card.
- Your Medicaid program number, if you have one.
- Your health insurance card(s) for any other insurance you carry besides Medicare and/or Medicaid. You can only enroll in one plan. Please be sure to clearly indicate which plan you wish to enroll in at the top of the form.
- Clearly and accurately provide all of the requested personal information. Make sure your birthday matches what is on file with Medicare and Social Security. If it does not match, your form will be denied. Make sure you accurately copy the information from your Medicare card.
- In the section titled “Attestation of Eligibility for an Enrollment Period,” please read the options and fill in the box that describes your situation. This section is significant. Horizon BCBSNJ determines which enrollment period is appropriate by the information and answers you provide in this section.
- DO NOT enter any information in “Agent Use Only” section.
- Please double- and triple-check that what you write on the form is correct and written clearly. It saves time in the long run. Do not forget to sign and date your enrollment form before mailing it back.
- Mail the form to:
Horizon Blue Cross Blue Shield of New Jersey
PO Box 10138
Newark, New Jersey 07101-9633
Disenrollment Rights and Protections
Ending your membership in our Plan may be voluntary (your own choice) or involuntary (not your own choice), but there are some exceptions.
If any of the following situations apply to you, you are eligible to end your membership during a Special Enrollment Period. These are just examples, for the full list you can contact the plan, call Medicare, or visit the Medicare website:
- Usually, when you have moved.
- If you have Medicaid.
- If you are eligible for “Extra Help” with paying for your Medicare prescriptions.
- If we violate our contract with you.
- If you are getting care in an institution, such as a nursing home or long-term care (LTC) hospital.
- If you enroll in the Program of All-inclusive Care for the Elderly (PACE).
Our Plan must end your membership in the plan if any of the following happen:
- If you do not stay continuously enrolled in Medicare Part A and Part B.
- If you move out of our service area.
- If you are away from our service area for more than six months. If you move or take a long trip, you need to call Member Services to find out if the place you are moving or traveling to is in our Plan’s area.
- If you become incarcerated (go to prison).
- If you lie about or withhold information about other insurance you have that provides prescription drug coverage.
- If you intentionally give us incorrect information when you are enrolling in our Plan and that information affects your eligibility for our Plan. (We cannot make you leave our Plan for this reason unless we get permission from Medicare first.)
- If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our Plan. (We cannot make you leave our Plan for this reason unless we get permission from Medicare first.)
- If you let someone else use your membership card to get medical care.
- If you are required to pay the extra Part D amount because of your income and you do not pay it, Medicare will disenroll you from our Plan and you will lose prescription drug coverage.
Because you have Medicaid, you may be able to end your membership in our plan or switch to a different plan one time during each of the following Special Enrollment Periods:
If you joined our plan during one of these periods, you’ll have to wait for the next period to end your membership or switch to a different plan. You can’t use this Special Enrollment Period to end your membership in our plan between October and December. However, all people with Medicare can make changes from October 15 – December 7 during the Annual Enrollment Period. For more information, see Chapter 9, section 2 of your plan’s Evidence of Coverage.
If you have any questions or would like more information on when you can end your membership: You can call Member Services or you can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
Service Area and Out-of-Network Coverage
Individuals residing in all 21 New Jersey counties are eligible to enroll in Horizon NJ TotalCare (HMO D-SNP).
You must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis or other services. If you obtain routine care from out-of-network providers neither Medicare nor Horizon NJ TotalCare (HMO D-SNP) will be responsible for the costs.
Drug Management Programs
Utilization management
For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacist developed these requirements and limits for our Plan to help us to provide quality coverage to our members. Examples of drug utilization review tools are described below:
- Prior Authorization: We require you to get prior authorization for certain drugs. This means that you, your physician or pharmacist will need to get approval from us before you fill your prescription. Without an approval, we may not cover the drug.
- Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time. For example, we will provide up to 42 tablets per prescription for Zofran 4mg tablets.
-
Step Therapy: In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.
Effective 2019, the Centers for Medicare & Medicaid Services allows health plans to implement a Drug Step Therapy program for certain Part B drugs. This Step Therapy Program encourages Medicare Advantage members to try less costly, but just as effective, Part B drugs before the plan covers another drug. We give you the information you need to take care of your health. The list of Part B drugs that are impacted by Horizon Blue Cross Blue Shield of New Jersey’s Step Therapy program is included below along with the Preferred Alternatives.Part B Drugs Preferred Alternative Drug(s) Aloxi Zofran, Kytril Sustol Aloxi, Zofran, Kytril Epogen/Procrit Biosimilar epoetin alfa (Retacrit) Neupogen Granix, Zarxio Fusilev Leucovorin Tysabri Multiple Sclerosis: Interferon beta (i.e. Avonoex, Rebif, Betaseron, Extavia), Copaxone
Crohn’s Disease: Immunosuppressants (5-ASA, 6-mercaptopurine, azathioprine, cyclosporine, methotrexate), TNF AntagonistLemtrada Avonex, Rebif, Betaseron, Extavia, Tysabri, Copaxone, Tysabri, Ocrevus, Tecfidera, Gilenya, Aubagio Vpriv Cerezyme, Cerdelga Elelyso Cerezyme, Cerdlega Prolia Reclast Xgeva Zometa - Generic Substitution: When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug.
You can find out if your drug is subject to these additional requirements or limits by looking in the formulary. If your drug does have these additional restrictions or limits, you can ask us to make an exception to our coverage rules. See the section, “Coverage Determination and Redetermination” for more information.
Drug utilization review
We conduct drug utilization reviews for all of our members to make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribe their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:
- Possible medication errors.
- Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition.
- Drugs that are inappropriate because of your age or gender.
- Possible harmful interactions between drugs you are taking.
- Drug allergies.
- Drug dosage errors.
If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.
Medication Therapy Management
The Horizon Blue Cross Blue Shield of New Jersey’s Medication Therapy Management Program (MTM program) is part of our Medicare prescription drug plans and Medicare Advantage plans with prescription drug coverage. The Centers for Medicare and Medicaid Services (also called CMS) requires all Medicare Part D sponsors to offer an MTM program to eligible members. To be eligible for Horizon Blue Cross Blue Shield of New Jersey’s MTM plan, you must:
- Have at least three chronic conditions from the list:
- Alzheimer’s/Dementia
- Diabetes
- Dyslipidemia
- Hypertension
- Depression
- Multiple Sclerosis
- Take eight or more Part D covered drugs to treat your chronic conditions.
- Have an expected cost of at least $4,376 a year or $1,094 per quarter for your Part D covered drugs in 2021.
How does the MTM program benefit me?
The MTM program was designed with your health as our top priority and is a service to use in addition to the conversations with your doctor and pharmacists. The aim of the MTM program is to work with you and your doctor to help you achieve and maintain the safest and most effective medication therapy for you. The program helps you, your doctor, and your health care team strengthen the management of medications by:
- Empowering you to take an active role in your health care experiences
- Providing you with education material to help you achieve and maintain your best level of health:
- Fact sheets on your chronic conditions.
- Tips and tricks.
- Information about nutrition and physical activity.
- Recommended goals.
- Providing you with the opportunity to speak with a live pharmacist.
- Performing targeted reviews every quarter to ensure there are no safety concerns, missed opportunities or issues such as:
- Taking similar medications.
- Gaps in therapy.
- Taking medicines with in U.S. Food and Drug Administration (FDA) guidelines.
- Interactions between your medications.
If there are any safety concerns, missed opportunities or issues, we will notify you, your doctor and/or your health care team by mail or telephone.
- Providing you, your doctor and your health care team with current information on your medications and chronic conditions.
Our team of trusted pharmacists may reach out to you or your doctor to alert you to any gaps in therapy or safety concerns. He or she will work with you to schedule an appointment to speak with one of our trusted pharmacists on the telephone to participate in a Comprehensive Medication Review.
What is a Comprehensive Medication Review?
CMS requires all MTM programs to complete a Comprehensive Medication Review with each member. A Comprehensive Medication Review (also called a CMR) is a review of all your prescription medications, over-the-counter medications (medications such as aspirin or heartburn pills), vitamins and herbal supplements with a trusted pharmacist over the telephone.
- A CMR can help you better understand your medications by explaining how they work best and what to watch out for.
- During a CMR you will receive personal attention from one of our trusted pharmacists without being rushed.
- Along with reviewing your medications, the pharmacist will answer your medication questions.
- The pharmacist can also help you with general answers to questions you have about your health.
- A written summary of the discussion, including a personal medication list with counseling points, will be sent to you for your personal records within 14 days of the review.
- A copy of the written summary will also be sent to up to three of your doctors so that you and your doctors can address your health issues together.
How much will the MTM program cost me?
The MTM program and its services are provided to you for no cost.
How will the MTM program affect my plan coverage?
The MTM program is not considered part of your plan benefits and will not affect your coverage in any way. The MTM program is a free health service program offered to eligible members.
How do I enroll in the MTM program?
You do not need to do anything to enroll in the MTM program. We will automatically enroll you and send you a welcome letter if you are eligible for the program. Along with the welcome letter, you will receive a short form to fill out and return to us in the postage paid envelope to help us schedule your CMR. You may also be called to schedule a CMR or you can call us directly to schedule a CMR or to speak with a pharmacist.
I have more questions…
To speak with one of Horizon Blue Cross Blue Shield of New Jersey’s MTM team members, call 1-888-706-2820, Monday through Friday, between 9 a.m. and 5:00 p.m., ET. Due to high call volume, you may get the MTM voicemail. Please leave your name and a call back number and your call will be returned promptly. Members who have hearing or speech difficulties should call our TTY line at 711, during the same hours.
You can write to us:
Horizon BCBSNJ MTM Program
PP-12Q
3 Penn Plaza East
Newark, NJ 07105
Appeals and Grievances
If you are looking for information regarding coverage decisions, making appeals or making complaints about your medical care, see Chapter 8 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints) in your Plan's Evidence of Coverage document also found on this website.
You may also call us if you have questions about our coverage decision process, appeals, complaints about your medical care or if you would like to obtain an aggregate number of complaints, appeals and exceptions with the plan sponsor. Please contact Member Services at 1-800-543-5656 (TTY 711). Calls to this number are free. Hours of Operation: October 1 – March 31: Monday – Sunday, from 8:00 a.m. to 8:00 p.m., ET; and, April 1 – September 30: Monday – Friday, from 8:00 a.m. to 8:00 p.m., ET.
Written medical appeal requests should be mailed to the following address:
Horizon NJ TotalCare (HMO D-SNP) Medical Appeals
P.O. Box 10196
Newark, NJ 07101-0406
Written claim appeals requests should be mailed to the following address:
Horizon NJ TotalCare (HMO D-SNP) Member Services
P.O. Box 24081
Newark, NJ 07101-0406
Complaints about medical care should be mailed to the following address:
Horizon NJ TotalCare (HMO D-SNP) Appeals and Grievances
P.O. Box 24079
Newark, NJ 07101-0406
If you prefer to send information by fax, please use the fax numbers below:
Medical appeal requests can be faxed to 609-583-3028
Complaints and Claim appeals requests can be faxed to 732-938-1340
You can also file grievances, organizational/coverage determinations or appeals with Medicare directly. You can go directly to their website by clicking here or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048
Home Delivery Pharmacy Services
Fill a new prescription with AllianceRx Walgreens Prime Home Delivery:
https://www.myprime.com/en/find-pharmacy/alliancerx-walgreens-prime.html
Part D Claim and Utilization Management Forms
Get your Medicare Prescription Drug Claim Form, as well as additional forms and information related to your Prescription Drug Utilization Management.
Forms and resources for your prescription drug plan:
https://www.myprime.com/v/HBCBSNJ/MEDICARE_D/NJDSNPHMO/en/forms.htmlFilling Prescriptions Outside of the Network
Your prescription may be covered in certain situations.
Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. To help you, we have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our Plan. If you cannot use a network pharmacy, here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:
- If you are traveling in the United States and territories and become ill, lose or run out of your prescription.
- If you were unable to get a covered drug in a timely manner. There was not a network pharmacy nearby that provided 24/7 service.
- If you were trying to fill a covered drug not regularly stocked at a network retail or mail order pharmacy.
- If you were evacuated or displaced due to a federally-declared disaster or other public health emergency declaration and could not get your drug at a network pharmacy.
- If you were provided a covered drug while in an emergency department, provider-based clinic, outpatient surgery, or other outpatient setting and could not get your drug filled at a network pharmacy.
We will cover your drug for a temporary 30-day supply of medication, or for fewer days, based on your prescription, for the circumstances above.
In these situations, please check first with Member Services to see if there is a network pharmacy nearby.
How do you ask for reimbursement from the plan?
If you must use an out-of-network pharmacy, you will generally have to pay the full cost at the time you fill your prescription. To request a reimbursement, mail your request for payment together with any receipts to us at this address:
Prime Therapeutics, LLC
P.O. Box 20970
Lehigh Valley, PA 18002-0970