Inquiry / Request

 Request Form - Dental - Credit for Deductible Carryover

If new members (and/or covered family members) have met all or part of their deductible under a prior dental plan, use this form to request that a credit be applied to their new plan. ID: 7263

 Request Form - Dental - Recruit Provider

Give this form to a dentist to invite him/her to join one or more Horizon BCBSNJ dental networks. ID: 9652

 Request Form - Medical - Credit for Deductible Carryover

If new members (and/or covered family members) have met all or part of their deductible under a prior Medical plan, use this form to request that a credit be applied to their new plan. ID: 7239

 Request Form - Pharmacy - Formulary Exception

Use this form to request that a member receive a medication that is not on the formulary at the same copay as the brand of medication that is on the formulary. ID: 6592

 Request for Continuance of Enrollment for Disabled Dependent (Groups 2-50)

Members with a mentally-impaired or physically-disabled child can use this form to request that the child continues to be covered by the parent’s dental plan. ID: 2407

 Request for Continuance of Enrollment for Disabled Dependent (Groups 51 Plus)

Members with a mentally-impaired or physically-disabled child can use this form to request that the child continues to be covered by the parent’s dental plan. ID: 9429