Medicare Banner

Enrollment Form


Horizon Medicare Blue Rx Standard (PDP) $63.80/monthly

IMPORTANT: By completing the online enrollment process, you will send an actual enrollment request, will receive an acceptance or denial notice following submission of the enrollment, and will be enrolled in a Horizon Blue Cross Blue Shield of New Jersey Medicare Advantage or Prescription Drug plan (if approved by CMS).

  • Current: About You
  • Important Questions
  • Payment Details
  • Authorization
  • Attestation
  • Preview
  • Done

Information About You

Information About You

Fields marked with an asterisk (*) are required.

Month Day Year

Permanent Residence (PO Boxes Not Allowed)

Permanent Residence (PO Boxes Not Allowed)
Horizon Blue services only available to New Jersey residents

Mailing Address

Mailing Address

Medicare Insurance Information

Medicare Insurance Information

Find In-Network Doctors

If you need to find a new doctor who participates in one of our networks, our Doctor & Hospital finder makes it easy to find a health care professional who matches your needs.

Find In-Network Pharmacies

Search from more than 66,000 in-network pharmacies at Prime Therapeutics.

Find Covered Prescription Drugs

Find formulary drugs, prior authorization, and step therapy at Prime Therapeutics.