Inquiry / Request Forms
Request For Termination
ID: 32233 (W0415)
Request Form - Certificate of Creditable Coverage
Need new coverage without a pre-existing condition exclusion? Use this form to request the proper Horizon BCBSNJ Certificate. ID: 6793
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 - HRA Check Reissue Form
ID: 32222
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 - Medical - Transition Care Benefit
Use this form to request Transition Care benefits. ID: 7164
Request Form - Pharmacy - Determination of Medicare Prescription Drug Coverage
Members who want exceptions to the Medicare prescription formulary and/or to copay tiering can use this form to request a Medicare prescription drug coverage determination. ID: H3154
Request Form - Pharmacy - Redetermination of Medicare Prescription Drug Denial
If Horizon BCBSNJ has denied a member coverage of or payment for a prescription drug, that member can use this form to appeal the decision (a "redetermination"). ID: H3154
Request Form – Merck Members – Flexible Spending Account – Check Reissue
If a Flexible Spending Account (FSA) reimbursement check is not received, this form is used to request a new one. ID: 16115
Request for Continuance of Enrollment for Disabled Dependent
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: 3796
Request to have Medical Records Transferred
Member request to have medical records transferred to a doctor or other healthcare professional. ID: 7953
