Horizon Medicare Blue Advantage (HMO)

Our Horizon Medicare Blue Advantage (HMO) plan allows us to offer Medicare Beneficiaries access to high-quality health care and lower out-of-pocket costs for the low premiums ($0 plan premium in some counties) that the New Jersey market is demanding.

As previously announced, 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.

A provider’s participation status in our new Horizon Medicare Blue Advantage (HMO) plan DOES NOT affect their provider participation in other Horizon BCBSNJ Medicare Advantage (MA) plans. Medicare-eligible beneficiaries enrolled in most of our 2018 MA plans have in-network access to all Horizon Managed Care Network participating physicians and other health care professionals and all Horizon Hospital Network facilities.

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 Availability
Based on market demand, the Horizon Medicare Blue Advantage (HMO) plan will be offered in 15 counties (Atlantic, Bergen, Cumberland, Essex, Hudson, Hunterdon, Mercer, Middlesex, Monmouth, Morris, Ocean, Somerset, Sussex, Union and Warren) throughout New Jersey.

The Horizon Medicare Blue Advantage (HMO) plan will not be offered to Medicare-eligible beneficiaries that reside in Burlington, Camden, Cape May, Gloucester, Passaic and Salem counties. However, members who reside in these counties will have other Medicare Advantage options with Horizon BCBSNJ.

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Horizon Medicare Blue Advantage (HMO) Plan Participation
Members that choose the Horizon Medicare Blue Advantage (HMO) plan will have access to a subset of the physicians and other health care professionals in the Horizon Managed Care Network, as well as a subset of facilities in the Horizon Hospital Network.

Members will also have access to all ancillary health care professionals in the Horizon Managed Care Network(some exceptions apply to in-network ancillary providers.)

There are no out-of-network benefits with the Horizon Medicare Blue Advantage (HMO) plan, except in the event of an emergency. Therefore, members must receive services from physicians, health care professionals and hospitals that participate in this plan.

Provider participation status in our new Horizon Medicare Blue Advantage (HMO) plan DOES NOT affect provider participation in other Horizon BCBSNJ Medicare Advantage plans.

As noted below, Medicare-eligible beneficiaries enrolled in most of our other MA plan offerings have in-network access to all Horizon Managed Care Network participating physicians and other health care professionals and all Horizon Hospital Network facilities.

Members enrolled in …

Have in-network access to …

  • Horizon Medicare Blue Value (HMO)
  • Horizon Medicare Blue Value with Rx (HMO)
  • Horizon Medicare Blue Choice w/Rx (HMO)
  • Horizon Medicare Blue Access Group (HMO-POS)
  • Horizon Medicare Blue Access Group w/Rx(HMO-POS)
  • Horizon Medicare Blue (PPO)
  • Horizon Medicare Blue Group (PPO)
  • Horizon Medicare Advantage NJ DIRECT10 (PPO)
  • Horizon Medicare Advantage NJ DIRECT15 (PPO)
  • ALL physicians and other health care professionals that participate in our Horizon Managed Care Network
  • ALL facilities in the Horizon Hospital Network
  • Horizon Medicare Blue Advantage (HMO)
  • A subset of physicians and other health care professionals that participate in the Horizon Managed Care Network
  • A subset of facilities in the Horizon Hospital Network

Physician and other health care professional participation
Participation in the Horizon Medicare Blue Advantage (HMO) plan is at the group practice level. All physicians and other health care professionals affiliated with, or who practice and render services while under or on behalf of a group practice, are either participating or nonparticipating when treating members under the group practice’s Tax ID Number (TIN).

  • All physicians and other health care professionals affiliated with a participating TIN will be considered in network when practicing with/on behalf of that participating group practice as it pertains to services rendered to Horizon Medicare Blue Advantage (HMO) plan members.
  • If a physician or other health care professional is also affiliated with a group practice that is not participating in this plan, that physician will be considered out of network for this plan when practicing with/on behalf of that nonparticipating group practice

For information about how physicians and other health care professionals in the Horizon Managed Care Network were evaluated for participation in this plan, please review the Horizon Medicare Blue Advantage (HMO) Plan Physician and Other Health Care Professionals Frequently Asked Questions which was also included with our September 2017 Horizon Medicare Blue Advantage (HMO) mailing.

Additional information can be found in our administrative policy, Participation Status in Products That Utilize Tiering and/or a Subset of an Existing Horizon Network. To access this information, please sign in 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 & Procedures and select Policies.
  • Select Administrative Policies.

Evaluation for participation in the Horizon Medicare Blue Advantage Plan (HMO) plan is independent of any program or plan offered by Horizon BCBSNJ. Each program and plan is based on a different set of criteria.

Doctor & Hospital Finder
Provider participation status for the Horizon Medicare Blue Advantage (HMO) plan may be reviewed 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.

PCPs will be reimbursed based on their current payment methodology.

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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
LabCorp® is the exclusive in-network provider of clinical laboratory services for members enrolled in the Horizon Medicare Blue Advantage (HMO) plan.

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 exclusivity requirement.

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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 and 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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Benefit Overview

Category Benefit
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.

Members must use providers that participate in the Horizon Medicare Blue Advantage (HMO) plan.

Members enrolled in this plan have no benefits for out-of-network services, except in the event of an emergency.
Primary Care Physician (PCP) Selection PCP selection is required.
Members must select a PCP that participates in the Horizon Medicare Blue Advantage (HMO) plan.
Referrals Referrals are NOT required.
Prior Authorization Certain services/supplies require prior authorization.
Well Care Eligible preventive services are covered at 100% with no member cost sharing. Limited to one routine physical per calendar year.
PCP Office Visit $10 copayment per visit to a pre-selected PCP that participates in the Horizon Medicare Blue Advantage (HMO) plan.
Specialist Office Visit $25 copayment per visit to a specialist that participates in the Horizon Medicare Blue Advantage (HMO) plan.
Deductible $0 deductible for medical/surgical services.
Diagnostic Tests/X-rays Diagnostic Tests and procedures:
20% coinsurance

X-Rays:
$15 copayment (in an office/freestanding facility place of service)
20% coinsurance (in an outpatient hospital place of service)

Diagnostic Radiology:
20% coinsurance for MRI/Advanced Imaging
Chiropractic $20 copayment
Medicare covered services only.
(Short-term Therapies in an office setting) $25 copayment per visit
Durable Medical Equipment (DME) 20% coinsurance
Benefits provided through the Horizon Care@Home program.
Chemotherapy Drugs 20% coinsurance
Administrative codes are considered professional and will pay 100% in the office only.
Inpatient Hospital (Acute) $320 copayment for days 1 through 5
$0 copayment for per days 6 & beyond
$1,600 out-of-pocket maximum per admission

If the out-of-pocket limit is met for an acute care hospital stay and a beneficiary is readmitted within three days of discharge for the same diagnosis, no copayments will apply to the readmission.

Substance use disorder is covered under Inpatient Hospital (Acute) and Inpatient Hospital Psychiatric Services (Benefits provided through the Horizon Behavioral Health program)
Emergency Room $80 copayment
Copayment will be waived if admitted within 24 hours for the same condition.
Urgent Care Center $20 copayment for participating Urgent Care Center
Ambulatory Surgical Center $270 copayment
Hospice Care Covered with no member cost share if care is provided by a Medicare-certified hospice.
Maximum Out-of-Pocket $6,700

Eligible cost sharing amounts that result from Part B claims processed at the pharmacy through Prime will be counted towards the medical MOOP. MOOP includes copayment and coinsurance amounts.
Hearing Exam (Routine) Routine hearing exams and fitting/evaluation for hearing aids must be coordinated through HearUSA.

$0 copayment for 1 annual routine exam
$0 copayment for 1 fitting/evaluation for hearing aid
Hearing Aids Hearing aids purchase must be coordinated through HearUSA.
$750 hearing aid allowance for one ear
$500 hearing aid allowance for second ear within 1- year benefit period
Vision Care (Routine) $0 copayment for routine annual exam
$100 eyewear reimbursement every 2 years

$0 copayment for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery.
Part D Pharmacy Deductible Part D deductible does not apply to Preferred generic drugs and non-Preferred generic drugs.

Part D deductible applies to Preferred brand drugs, non-Preferred brand drugs, and specialty drugs.

Part D deductible varies by the county in which the beneficiary resides:
  • $0 Part D deductible: Atlantic, Cumberland and Morris counties.
  • $285 Part D deductible: Bergen, Essex, Hudson, Mercer, Middlesex, Monmouth, Ocean and Union counties.
  • $345 Part D deductible: Hunterdon, Somerset, Sussex and Warren counties.
Part D Pharmacy Cost Sharing Preferred Pharmacy Arrangement:
Members have a preferred (reduced) cost sharing responsibility when using certain preferred pharmacies including: CVS, Wakefern (Shoprite), Walmart, Prime Specialty Pharmacy (PSP), BriovaRx, Elevate, Epic, Ahold (Stop & Shop). The standard cost sharing will apply when using other pharmacies.

Preferred Generic: $1 preferred copayment / $8 standard copayment

Non-Preferred Generic: $9 preferred copayment / $16 standard copayment

Preferred Brand: $40 preferred copayment / $47 standard copayment

Non Preferred Brand: $60 preferred copayment / $70 standard copayment

Specialty Drugs: Specialty drug coinsurance amounts vary by the county in which the beneficiary resides:
  • 27% coinsurance for Bergen, Essex, Hudson, Mercer, Middlesex, Monmouth, Ocean and Union counties.
  • 26% coinsurance for Hunterdon, Somerset, Sussex and Warren counties.
  • 33% coinsurance for Atlantic, Cumberland and Morris counties.

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

  • Prior-authorization requests
    1-800-664-2583
  • Behavioral health and substance use disorder
    Please call Horizon Behavioral Health 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 patients enrolled in the Horizon Medicare Blue Advantage (HMO) plan 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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Mailing/Contact Information

Claims
Claims for services provided to members enrolled in the Horizon Medicare Blue Advantage (HMO) plan may be submitted electronically. Claims may also be submitted hard copy to the following addresses:

Type of service Claim submission address Inquiry submission address
Professional Horizon BCBSNJ
PO Box 1609
Newark, NJ 07101-1609
Horizon BCBSNJ
PO Box 199
Newark, NJ 07101-0199
Facility Horizon BCBSNJ
PO Box 25 
Newark, NJ 07101-0025
Horizon BCBSNJ
PO Box 1770
Newark, NJ 07101-1770
Pharmacy Prime Therapeutics
PO Box 64812 
St. Paul, MN 55164-4812
Prime Therapeutics
P.O. Box 64812
St. Paul, MN 55164-4812

Service
Horizon BCBSNJ has a number of service areas that can assist with authorizations and PAs. For these specialized service areas to perform their functions 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 contacting our Precertification Call Center 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.

Service area Phone number
Dental 1-800-4-DENTAL (433-6825)
eviCore healthcare 1-866-496-6200
Horizon Behavioral Health 1-800-626-2212
Horizon Care@Home Program 1-855-243-3321
Horizon Pharmacy Program 1-800-391-1906
Institutional Services 1-888-666-2535
Medical Injectables Program 1-800-424-4508
Member Services 1-800-355-BLUE (2583)
Physical Therapy Unit 1-888-789-3457
Physician Services 1-800-624-1110
Prior Authorization Requests 1-800-664-BLUE (2583)

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Member ID Cards

Horizon BCBSNJ member ID cards contain the important information you need in a consistent layout so that our ID cards are easy to read and use. Members enrolled in the Horizon Medicare Blue Advantage (HMO) plan have ID cards similar to the sample ID card below.

Please note that the YKO prefix included on Horizon Medicare Blue Advantage (HMO) plan ID cards is not exclusive to this plan. The YKO prefix is also included on ID cards for members enrolled in other Horizon BCBSNJ Medicare Advantage plans.

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