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 - 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