Access printable forms that you can use to manage your Horizon MyWay account.
Merck Daycare Expense Reimbursement Claim Form
Use this form to file a Horizon BCBSNJ Health Flexible Spending Account (FSA) claim for eligible dependent child or adult daycare expenses.
ID: 32356 X22115R06 (08/22)
Merck Flexible Spending Account (FSA) Authorization for Direct Deposit
This form authorizes Horizon BCBSNJ to make a bank account deposit for a Flexible Spending Account (FSA).
ID: 32355 X22112R06 (08/22)
Merck Flexible Spending Account (FSA) Letter of Medical Necessity (LOMN)
Under Internal Revenue Service rules, some health care services and products are only eligible for reimbursement from your spending account when your doctor or eligible licensed health care provider certifies that they are medically necessary. Please use this letter to provide the information needed to process your claim. Your provider must indicate the patient’s diagnosis, the recommended treatment needed, and how this treatment will alleviate the medical condition. Be sure to send this LOMN with your completed medical reimbursement form.
ID: X22224R04 (8/22)
Merck Medical Expense Reimbursement Account Claim Form
Use this form to file a Horizon BCBSNJ Health Flexible Spending Account (FSA) claim for eligible expenses incurred by you or your eligible dependents.
ID: 32357 X22141R06 (08/22)
Merck Reimbursement Return Form
To return overpaid funds to a spending account, use the Reimbursement Return Form
ID: X22226R04 (08/22)