Horizon Medicare Blue Advantage (HMO)
For 2022, the Horizon Medicare Blue Advantage (HMO) plan will be offered to Medicare-eligible beneficiaries in eight New Jersey counties: Atlantic, Cumberland, Hunterdon, Mercer, Morris, Somerset, Sussex and Warren.
Features of our Horizon Medicare Blue Advantage (HMO) Plan:
- Primary Care Physician (PCP) selection is required.
- No referrals.
- Certain services/supplies require prior authorization.
- Routine vision, hearing and dental benefits are included.
- All preventive care services identified by the federal health care reform law are covered at 100 percent without any cost sharing when provided by a participating health care professional.
- Pharmacy benefit is included. Prime Therapeutics LLC is the pharmacy benefits manager.
- No out-of-network benefits, except in cases of medical emergencies.
- BlueCard® (out-of-area) coverage is not included.
The Horizon Medicare Blue Advantage (HMO) plan uses a subset of physicians and other health care professionals who participate in the Horizon Managed Care Network, as well as a subset of facilities in the Horizon Hospital Network.
Physicians, other health care professionals and hospitals not participating in the Horizon Medicare Blue Advantage (HMO) plan are considered out of network.
Participation 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 ancillary health care professionals in the Horizon Managed Care Network are considered participating in this plan. Some exceptions may apply.
Check the Doctor & Hospital Finder to confirm your participation status for the Horizon Medicare Blue Advantage (HMO) plan.
The evaluation criteria for the Horizon Medicare Blue Advantage (HMO) plan is available in our Participation Status in Products that Utilize Tiering and/or a Subset of an Existing Horizon Network administrative policy.
To access this policy, please log on to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu and:
- Mouse over References and Resources and click Provider Reference Materials.
- Mouse Policies & Procedures and click Policies.
- Click Administrative Policies.
Benefits, Eligibility and Cost-Sharing Information
Sign in to NaviNet to:
- Check member eligibility and plan details.
- View the member’s ID card.
- Use the Eligibility and Benefits Cost Share Estimator to check member cost share.
To access the Eligibility and Benefits Cost Share Estimator, sign in to NaviNet and from the Horizon plan central page:
- Select Eligibility and Benefits from the Workflows for this Plan menu.
- Click on Cost Share Estimator.
Sending Patients for Additional Care
Referrals are not required for members enrolled in the Horizon Medicare Blue Advantage (HMO) plan.
However, if a patient enrolled in the Horizon Medicare Blue Advantage (HMO) plan asks for your recommendation or guidance about the selection of a hospital or specialist, please remember (and convey to your patient) that Horizon Medicare Blue Advantage (HMO) plan members do not have out-of-network benefits (except in the event of an emergency).