Out-of-Network Provider Form to be Required for the Medical Injectable Program

Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) has revised the Consent for Referral to an Out-of-Network Provider Form to apply to specialty pharmacy and home infusion medical providers. As part of our Medical Injectables Program (MIP), Horizon BCBSNJ requires participating practitioners to complete this revised form when using out-of-network specialty pharmacies and home infusion medical services.

You must complete and submit a specialty pharmacy version of the Consent for Referral to an Out-of-Network Provider Form¹ when recommending the use of a nonparticipating specialty pharmacy or home infusion health care professional to supply or render drugs and/or services to a patient enrolled in a Horizon BCBSNJ plan that includes out-of-network benefits.

Completion and submission of our Consent for Referral to an Out-of-Network Provider Form, signed by the patient/member, is required as per the guidelines of our Out-of-Network Referral Policy.2 This policy helps ensure that members enrolled in plans with out-of-network benefits are made aware in advance when their doctor plans to recommend the use of a nonparticipating provider. The policy also helps ensure that our members understand they may be responsible for significantly higher total out-of-pocket costs when using a nonparticipating provider.

Magellan Rx Management will request a completed consent form from referring/prescribing doctors who are referring their patients to out-of-network specialty pharmacies or home infusion providers. This is part of the medical necessity and appropriateness reviews they perform for specific high-cost injectable medications on our behalf through our MIP. A copy of the revised Consent for Referral to an Out-of-Network Provider Form is enclosed. Additional forms may be obtained through Magellan Rx Management at the time services are requested to be reviewed.

Step-by-Step Instructions:

1. Complete this form before using an out-of-network specialty pharmacy or home infusion health care professional.
2. Have a discussion with your patient (or his/her parent, guardian or personal representative) before using an out-of-network specialty pharmacy or home health care professional to provide/administer medical injectable drugs to advise that:
   • An out-of-network specialty pharmacy or home health care provider will be involved in your patient’s care
   • Claims for services provided by an out-of-network specialty pharmacy or home health care professional will be processed at your patient’s out-of-network level of benefits
   • Your patient will be responsible for any applicable out-of-network cost sharing amounts (copays, deductible and/or coinsurance amounts) AND the difference between Horizon BCBSNJ’s allowance for eligible services and the out-of-network provider’s billed charges.
   • A member’s out-of-pocket costs may be significantly higher when using an out-of-network provider
3. Have your patient (or the guardian or personal representative) initial/sign this form to attest that the patient:
   • Is aware of and agrees to the use of an out-of-network specialty pharmacy or home health care professional
   • Understands the financial impact of the decision to use an out-of-network specialty pharmacy/home infusion health care professional
4. Once the form is completed and signed, you must:
   • Retain the original completed form in your patient’s medical record
   • Provide a copy to your patient
   • Fax a copy to Horizon BCBSNJ Pharmacy Department at 1-973-274-2285

If you have questions, please call Physician Services, 1-800-624-1110, weekdays, from 8 a.m. to 5 p.m., Eastern Time.

1. The completion of our Member Referral Consent Form: Using an Out-of-Network Provider for Medical Injectable Drugs replaces your need to complete a copy of our Consent for Referral to an Out-of-Network Provider Form. The form will only be provided by MRxM.

2. Our Out-of-Network Referral Policy does not apply to members enrolled in plans that do not include out-of-network benefits (e.g., Horizon HMO, Horizon EPO, OMNIASM Health Plans, Horizon Medicare Blue Value [HMO]). Please do not complete our Consent for Referral to an Out-of-Network Provider Form for patients enrolled in these plans.

   To access our Out-of-Network Referral Policy, log on to NaviNet.net, select Horizon BCBSNJ from the

   My Health Plans menu, and:

   • Mouse over References and Resources and select Provider Reference Materials.
   • Mouse over Policies and Procedures and select Policies.
   • Select Administrative Policies.

Magellan Rx Management MNAR determination is for benefit and coverage purposes and is not a guarantee of payment. Claim reimbursement is subject to member eligibility and all member and group benefit limitations, conditions and exclusions in force at the time services are rendered. Magellan Rx Management is an independent company that supports Horizon Blue Cross Blue Shield of New Jersey in the administration of medical necessity and appropriateness review (MNAR) for certain medical injectable drugs. Magellan Rx Management is independent from and not associated with Horizon Blue Cross Blue Shield of New Jersey. Magellan Rx Management is a service mark of Magellan Health, Inc.