Horizon Medicare Blue Advantage (HMO)

Features of our Horizon Medicare Blue Advantage (HMO) plan:

• Primary Care Physician (PCP) selection is required for members enrolled in the Horizon Medicare Blue Advantage (HMO) plan
• Referrals are not required for Horizon Medicare Blue Advantage (HMO) plan members.
• Prior authorization is required for certain services/supplies.
• Routine vision, hearing and dental benefits are included.
• Horizon Medicare Blue Advantage (HMO) plans do not include out-of-network benefits.
  
  Horizon Medicare Blue Advantage (HMO) plan members must use physicians, other health care professionals and facilities that participate specifically in the Horizon Medicare Blue Advantage (HMO) plan, except in cases of medical emergencies.
  
  Physicians, other health care professionals and hospitals not participating in the Horizon Medicare Blue Advantage (HMO) plan are considered out of network.

Learn more about our Horizon Medicare Blue Advantage (HMO) Plans.

• Horizon Medicare Blue Advantage (HMO) Plan Participation
• Primary Care Physician (PCP) Selection
• Referrals
• Out-of-Network Benefits
• BlueCard® (out-of-area) Benefits
• Preventive Care
• Clinical Laboratory Services
• Prescriptions
• Reimbursement
• Prior Authorization/Precertification
• Participating Physician Responsibilities

Horizon Medicare Blue Advantage (HMO) Plan Participation
The Horizon Medicare Blue Advantage (HMO) plan uses a subset of physicians and other health care professionals that participate in the Horizon Managed Care Network, as well as a subset of facilities in the Horizon Hospital Network.

To make it easier for members to understand their cost sharing responsibilities, participation in the Horizon Medicare Blue Advantage (HMO) plan is at the group level. All physicians and other health care professionals who bill for services under the group practice’s Tax ID Number (TIN) are considered either participating or nonparticipating when treating members.

• All physicians and other health care professionals affiliated with a participating TIN are considered in-network when they bill for services rendered to Horizon Medicare Blue Advantage (HMO) plan members under that participating group practice’s TIN.
• • If a physician or other health care professional is also affiliated with a group practice that is not participating in this plan, that physician is considered out of network for this plan when they bill for services rendered to Horizon Medicare Blue Advantage (HMO) plan members under that nonparticipating group practice as it pertains to services rendered to Horizon Medicare Blue Advantage (HMO) plan members.

All ancillary health care professionals in the Horizon Managed Care Network (some exceptions apply to in-network ancillary providers) are considered participating in this plan.

Physician and other health care professional participation
To make it easier for members to understand their cost sharing responsibilities, participation in the Horizon Medicare Blue Advantage (HMO) plan is at the group level. All physicians and other health care professionals who bill for services under the group practice’s Tax ID Number (TIN) are considered either participating or nonparticipating when treating members.

• All physicians and other health care professionals affiliated with a participating TIN are considered in-network when they bill for services rendered to Horizon Medicare Blue Advantage (HMO) plan members under that participating group practice’s TIN.
• If a physician or other health care professional is also affiliated with a group practice that is not participating in this plan, that physician is considered out of network for this plan when they bill for services rendered to Horizon Medicare Blue Advantage (HMO) plan members under that nonparticipating group practice as it pertains to services rendered to Horizon Medicare Blue Advantage (HMO) plan members.

Doctor & Hospital Finder
You can review your provider participation status for the Horizon Medicare Blue Advantage (HMO) plan as well as other Horizon BCBSNJ plans in our Doctor & Hospital Finder.

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Primary Care Physician (PCP) Selection
PCP selection is required for members enrolled in the Horizon Medicare Blue Advantage (HMO) plan. Members will be required to select a PCP who is participating in the Horizon Medicare Blue Advantage (HMO) plan.

Horizon Medicare Blue Advantage (HMO) plan members will appear on participating PCP panels.

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Referrals
Referrals are not required for members enrolled in the Horizon Medicare Blue Advantage (HMO) plan.

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Out-of-Network Benefits
The Horizon Medicare Blue Advantage (HMO) plan does not include out-of-network benefits (except in the event of an emergency).

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BlueCard® (out-of-area) Benefits
The Horizon Medicare Blue Advantage (HMO) plan does not include BlueCard (out-of-area) benefits. In the event of an emergency, members should go to the nearest Emergency Room regardless of participation status.

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Preventive Care
The Horizon Medicare Blue Advantage (HMO) plan covers the all preventive care services identified by the federal health care reform law at 100 percent without any cost sharing (i.e., copayment, coinsurance or deductible amounts) when provided by a physician or other health care professional who participates in the Horizon Medicare Blue Advantage (HMO) plan.

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Clinical Laboratory Services
Members enrolled in the Horizon Medicare Blue Advantage (HMO) plan have a choice of receiving care for in-network laboratory services at LabCorp and Quest Diagnostics. Members are encouraged to check for in-network laboratories.

Pathology services provided in a hospital setting to members enrolled in Horizon BCBSNJ managed care plans by a practice that participates in the Horizon Medicare Blue Advantage (HMO) plan are allowed as an exception to the above-described LabCorp/Quest network use requirements.

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Prescriptions
The Horizon Medicare Blue Advantage (HMO) plan includes a pharmacy benefit.

Prime Therapeutics LLC is the pharmacy benefits manager. Prior authorization (PA) may be required for some medications. Submit your pharmacy PA requests through NaviNet® or call 1-888-214-1784 if you have questions about a medicine requiring PA.

Prime Therapeutics LLC is independent from and not affiliated with Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross Blue Shield Association.

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Reimbursement
Eligible services provided to Horizon Medicare Blue Advantage (HMO) plan members by participating physicians and other health care professionals will be reimbursed at their current fee schedule.

The Horizon Medicare Blue Advantage (HMO) plan does not include out-of-network benefits except in the event of an emergency.

The following rates will apply for out-of-network care rendered to Horizon Medicare Blue Advantage (HMO) plan members in the ER or for inpatient admission as a result of an ER visit:

• If the physician is only participating in the Horizon PPO network, reimbursement will be based on amounts the physician would have received through Original Medicare.
• If the physician is participating in the Horizon PPO Network and the Horizon Managed Care Network but nonparticipating in the Horizon Medicare Blue Advantage (HMO) plan, reimbursement will be based on amounts the physician would have received through Original Medicare.

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Prior Authorization/Precertification
Certain services/supplies require prior authorization.

• Prior-authorization requests: 1-800-664-2583
• Horizon Behavioral Health (including substance use disorder) at 1-800-626-2212.
• Physical Therapy Unit: 1-888-789-3457
• Medical Injectables Program:
  For certain intravenous immunoglobulin (IVIG), oncology and rheumatoid arthritis injectable medications, please call Magellan Rx Management at 1-800-424-4508.
• eviCore healthcare:
  For non-emergency radiology services, advanced imaging services (MRI, CT, PET scans and nuclear medicine including nuclear cardiology), cardiac imaging services, radiation therapy and pain management services please call eviCore healthcare at 1-866-496-6200.
• Horizon Care@Home Program services:
  For DME (including medical foods [enteral] and diabetic and other medical supplies); orthotics and prosthetics; and home infusion therapy services, call 1-855-243-3321.

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Participating Physician Responsibilities

Participating Network
Horizon Medicare Blue Advantage (HMO) plan members must use physicians, other health care professionals and facilities that participate in the Horizon Medicare Blue Advantage (HMO) plan.

Horizon Medicare Blue Advantage (HMO) plan members have no out-of-network benefits (except in the event of an emergency).

Please use our Doctor & Hospital Finder to locate Horizon Medicare Blue Advantage (HMO) participating hospitals, physicians, other health care professional and ancillary providers.

Referrals
Referrals are not required for members enrolled in the Horizon Medicare Blue Advantage (HMO) plan.

However, if a patient is enrolled in the Horizon Medicare Blue Advantage (HMO) plan asks for your recommendation or guidance in regard to the selection of a hospital or specialist, please remember (and convey to your patient) that Horizon Medicare Blue Advantage (HMO) plan members have no out-of-network benefits (except in the event of an emergency).

Please use (or direct your Horizon BCBSNJ patients to) our Doctor & Hospital Finder to locate physicians, other health care professionals and facilities that participate in Horizon Medicare Blue Advantage (HMO).

Prior Authorization (PA)
Certain services require PA. Review a list of services that require PA.

Prescription Drug PA
Certain prescription drugs require PA.

We encourage you to use the NaviNet Drug Authorization tool to quickly and easily submit and manage your drug PAs. Access NaviNet Drug Authorizations to register and for more information. Physicians are encouraged to prescribe appropriate first-line agents before using alternative drugs.

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Service
Horizon BCBSNJ has a number of service areas that can assist with authorizations and PAs. For these specialized service areas to work efficiently and effectively, it’s important that their time is not spent responding to basic benefits, enrollment and eligibility inquiries.

Please seek basic benefits, enrollment and eligibility information prior to calling for an authorization request. If you require documentation that a service does not require precertification, a Physician Services Representative can provide both the information you need and a service reference number that documents the information you were provided.

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