How can we help?

No-cost flu shots are available to Horizon BCBSNJ members with medical benefits who are enrolled in a fully insured¹ plan or a self-insured² plan.

To get a no-cost flu shot or other vaccination, members must use pharmacies in New Jersey that are contracted with Horizon BCBSNJ’s medical network to provide immunizations. If you live outside of New Jersey, you can go to a MinuteClinic® at select CVS locations. Find a pharmacy near you that offers no-cost flu shots. Or, call your doctor.

You can find out if you need prior authorization for a specific service or treatment by signing in and following these steps:

1. Click Benefits & Coverage.
2. Click What’s Covered.
3. Select the correct tab - Medical, Dental, Prescription, as appropriate.
4. From the dropdown menu marked Service you may need, select the service you want to check and click Show Coverage Details.
5. Check the chart(s) to see if prior authorization is required. It will say Yes or No under the column heading Prior Authorization. You may need to scroll down to view all the information you need.

Prior authorization is the written approval from Horizon, prior to the date of service, for a doctor or other health care professional or facility to provide specific services or supplies. It is sometimes called pre-authorization, prior approval or pre-certification. Your Horizon plan may require prior authorization for certain services before you receive them, except in an emergency. Prior authorization isn’t a promise your health insurance or plan will cover the cost. Your participating doctor will work with Horizon to obtain prior authorization.

To find a participating doctor or hospital outside of New Jersey, please visit our Doctor & Hospital Finder and follow the steps below:

1. Under “What type of care are you looking for?”, choose between Medical, Behavioral Health, Dental or Vision.
2. Enter the appropriate health plan, if applicable (when you are signed in, the menu defaults to Your Plan), and the location outside of New Jersey.
3. You will be redirected to click National Doctor & Hospital Finder.

If you have a PPO-in-a-suitcase logo on your member ID card, you have access to the doctors, hospitals and other health care professionals of Blue Cross and Blue Shield Plan networks across the country. If you have a logo with a blank suitcase on your member ID card, you have in-network access across the country for emergency care only.

You should only have to pay the local Blue Plan’s negotiated rate and any out-of-pocket costs (such as deductible, copayment or coinsurance) that you would normally be responsible for under your PPO plan.

The doctor or hospital will submit the claim to the local Blue Plan for you. After your claim is processed, you will receive an Explanation of Benefits (EOB) statement from Horizon BCBSNJ.

Use our Doctor & Hospital Finder to find an in-network doctor, dentist, hospital, or other health care professional and follow the steps below:

1. Under “What type of care are you looking for?”, choose between Medical, Behavioral Health, Dental or Vision.
2. Enter the appropriate health plan and location, if applicable (when you are signed in, the menu defaults to Your Plan).
3. Begin typing in search criteria, such as the doctor’s or health care professional’s last name, or name of the hospital, or the specialty. Click from the results that best matches your input.

The results page will show doctors, hospitals or other health care professionals that accept the plan you chose and the information you set, such as city and state. You can find out who is joining and leaving the plan based on your search results. You can also search for a doctor by group practice.

You can view more details about the doctor or health care professional by clicking the View Profile button. Once signed in, you can also write a review, read other reviews and export results to a PDF document to print.

You can view your benefits information, including whether you have out-of-network benefits, by signing in and following the steps below:

1. Click Benefits & Coverage.
2. Click Benefits Overview.
3. Select the correct tab - Medical, Dental, Prescription or Vision, as appropriate.
4. Scroll down to Plan Details.
5. The “Out of Network” column will show in the chart only if you have out-of-network benefits. If you are an OMNIA Health Plan member, you will see tabs for OMNIA Tier 1 and Tier 2.

Important information about out-of-network costs: If an out-of-network doctor or other health care professional charges more than the amount that Horizon BCBSNJ has agreed to pay them (the “allowed amount”) for a service, the doctor or health care professional may bill you for the remaining amount, or the difference. When you are billed for the difference, this is referred to as “balance billing.”

Example: If an out-of-network doctor’s total charge is $100, and the allowed amount (the amount that Horizon BCBSNJ has agreed to pay the doctor for that service) is $70, the doctor may bill you for the remaining $30. You will be required to pay this amount in addition to any copayment, deductible or coinsurance you owe. Refer to your Explanation of Benefit (EOB) statement to see your list of out-of-pocket costs.

If your health plan includes benefits for out-of-network services or supplies, and you choose to go out of network, you generally will pay more out-of-pocket than if you used in-network providers. In addition, out-of-network providers are not contractually required to accept Horizon BCBSNJ’s reimbursement as full payment for the services and may bill you for the balance of the charges above Horizon BCBSNJ’s reimbursement.

If you do not have out-of-network benefits as part of your plan (i.e. OMNIA Health Plans), you will have to pay the entire amount the provider charged.

The majority of our members have prescription benefits through Prime Therapeutics. Please check the back of your Horizon BCBSNJ member ID card for the Prime Therapeutics logo. For Prime Therapeutics prescription benefit information, sign in and follow the steps below:

1. Click Doctors & Care.
2. Click Prescriptions.
3. Click Go to Your Prime Therapeutics.

Once signed in, you can:

1. Refill, renew and transfer prescriptions to PrimeMail by Walgreens Mail Service, Prime Therapeutics’ prescription home delivery service.
2. Check the status of your home delivery service.
3. Review your prescription history and cost information.
4. Find medicines, cost and coverage information.
5. Search pharmacies in your network.

If you do not have Prime Therapeutics as your pharmacy benefits manager through Horizon BCBSNJ, please contact your benefits administrator directly for more information.

Learn more about the Horizon Pharmacy Program.

Option B: For those members who do not use Prime Therapeutics for their pharmacy benefits: You can view your prescription benefits by following these steps:

1. Click Benefits & Coverage.
2. Click the Prescription tab in Benefits Overview.
3. Then check the chart(s) to see if this benefit is covered and if you need prior authorization. You may need to scroll down to view all the information you need.

You can find out if you are covered for diagnostic tests, such as X-rays and MRIs, by signing in and following these steps:

1. Click Benefits & Coverage.
2. Click What’s Covered.
3. Under the Medical tab, go to the dropdown menu titled Service you may need to select the correct type of diagnostic service (Diagnostic X-Ray or MRI/Cat Scan) and click Show Coverage Details.
4. Then check the chart(s) to see if the benefit is covered, how much your plan will pay, and if prior authorization is required. You may need to scroll down to view all the information you need.

Check the column titled Prior Authorization if it is required for this benefit. Your in-network doctor or other health care professional or hospital will be responsible for requesting prior authorization for you.

You can also get help scheduling your test at a participating facility by calling 1-866-969-1234.

You can find out if you are covered for chiropractic care by signing in and following these steps:

1. Click Benefits & Coverage.
2. Click What’s Covered.
3. Under the Medical tab, go to the dropdown menu titled Service you may need to select Chiropractic and click Show Coverage Details.
4. Then check the chart(s) to see if the benefit is covered, how much your plan will pay, how many sessions are covered and if prior authorization is required. You may need to scroll down to view all the information you need.

To find a participating chiropractor, visit our Doctor & Hospital Finder and click Medical. Then, type Chiropractic Medicine.