Horizon MyWay


Access printable forms that you can use to manage your Horizon MyWay account.


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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 F7415R18 (09/20)


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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: X22224R02 (09/20)


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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 F8503R10 (09/20)


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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 F8420R11 (09/20)


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Merck Reimbursement Return Form

To return overpaid funds to a spending account, use the Reimbursement Return Form

ID: X22226R01 (09/20)