Horizon Medicare Blue Patient-Centered w/Rx (HMO)

Building upon the success of our patient-centered programs, which include our participating Patient-Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs) programs, Horizon Blue Cross Blue Shield of New Jersey is pleased to offer the Horizon Medicare Blue Patient-Centered w/Rx (HMO) plan to Medicare-eligible members beginning in January 2015.

Horizon Medicare Blue Patient-Centered w/Rx (HMO) uses a subset of health care professionals who participate in the Horizon Managed Care Network. This plan also promotes and encourages the use of our patient-centered programs by offering lower member cost share when members preselect and use Primary Care Physicians (PCPs) affiliated with PCMHs and ACOs.

Enrolled members incur a higher copayment when they select and use PCPs who participate with the Horizon Medicare Blue Patient-Centered w/Rx (HMO) plan, but who are NOT affiliated with one of our established PCMH or ACO practices.

Members have no benefits for services rendered by physicians and health care professionals who do not participate with the Horizon Medicare Blue Patient-Centered w/Rx (HMO) plan except in the event of an emergency.

Use our Doctor & Hospital Finder to locate a doctor, other health care professional, hospital or ancillary provider that participates in the Horizon Medicare Blue Patient-Centered w/Rx (HMO) plan. Advance Search capabilities allow users to search specifically for providers affiliated with one a patient-centered program.

  • For this plan:
  • PCP selection is required.
  • Referrals are required.
  • Eligible preventive services, screenings and immunizations are covered with no member cost share when services are received from an in-network provider.
  • All hospitals in our current Horizon Hospital Network participate in Horizon Medicare Blue Patient-Centered w/Rx (HMO) product.
  • All in-network ancillary professionals and ancillary facilities participate with the Horizon Medicare Blue Patient-Centered w/Rx (HMO) plan.

Click the links below to learn more about Horizon Medicare Blue Patient-Centered w/Rx (HMO).

Horizon Medicare Blue Patient-Centered w/Rx (HMO) Benefits Overview

Participation Members must use providers that participate with the Horizon Medicare Blue Patient-Centered w/Rx (HMO) plan.
Primary Care Physician (PCP) Selection PCP selection is required.
Members incur lower cost sharing when they preselect and use a PCP affiliated with one of our participating PCMH and/or ACO practices.
Referrals Referrals are 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 or $15 copayment per visit to a preselected PCMH/ACO PCP

$35 copayment per visit to a preselected PCP who participates with the Horizon Medicare Blue Patient-Centered w/Rx (HMO) plan who is not affiliated with a PCMH/ACO practice.
Specialist Office Visit $50 copayment per visit to a specialist who participates with the Horizon Medicare Blue Patient-Centered w/Rx (HMO) plan.
Deductible $0 deductible
Diagnostic Tests/X-rays Office: $50 copayment Outpatient: 80% coinsurance
Chiropractic $20 copayment per visit. Limited to 30 visits/calendar year.
Short-term Therapies in an office setting) $40 copayment per visit. Limited to a combined 30 visits per calendar year for physical, speech, occupational and cognitive therapies performed in an office setting.
DME 80% coinsurance
Chemotherapy Drugs 80% coinsurance in all places of service. Administrative codes are considered professional and will reimburse at 100% in the office only.
Inpatient Hospital (Acute) $375 copayment per day (for days 1-4) and $237 copayment (for day 5)(Not to exceed $1,737)

$325 copayment per day (for days 1-5) (Not to exceed $1,625)
Emergency Room $65 Copayment per visit.
Urgent Care Center $40 Copayment per visit.
Ambulatory Surgical Center $325 or $250 Copayment per visit.
Hospice Care Covered with no member cost-sharing if care is provided by a Medicare-certified hospice
Maximum Out-of-Pocket $6,700

Participation

Physicians and other Health Care Professionals

Horizon Medicare Blue Patient-Centered w/Rx (HMO) uses a subset of physicians and health care professionals that participate in the Horizon Managed Care Network.

Members only have benefits when they use practitioners that participate in the Horizon Medicare Blue Patient-Centered w/Rx (HMO) product. Members have no benefits for services rendered by providers who do not participate in this product except in the event of an emergency.

To make it easier for our members, participation with Horizon Medicare Blue Patient-Centered w/Rx (HMO) is determined at the group level. All physicians and other health care professionals who practice within a particular group practice are either included or excluded.

Use our Doctor & Hospital Finder to locate a physician or other health care professional who participates in the Horizon Medicare Blue Patient-Centered w/Rx (HMO) product. Advance Physician Search capabilities allow users to search specifically for providers in Patient-Centered Programs.

Hospitals

All hospitals in our current Horizon Hospital Network participate in Horizon Medicare Blue Patient-Centered w/Rx (HMO) product. Use the Hospitals tab within our Doctor & Hospital Finder to locate a network hospital.

Ancillary Providers

All participating ancillary professionals and ancillary facilities participate in Horizon Medicare Blue Patient-Centered w/Rx (HMO) product. Use the Other Healthcare Services tab within our Doctor & Hospital Finder to locate an ancillary professional or facility who participates in the Horizon Managed Care Network.

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Primary Care Physician (PCP) Selection

PCP selection is required for members enrolled in the Horizon Medicare Blue Patient-Centered w/Rx (HMO) product. Please note that Horizon Medicare Blue Patient-Centered w/Rx (HMO) uses a subset of PCPs that participate in the Horizon Managed Care Network. Although the majority of managed care network PCPs are participating, NOT ALL managed care PCPs were selected for participation with Horizon Medicare Blue Patient-Centered w/Rx (HMO).

Horizon Medicare Blue Patient-Centered w/Rx (HMO) uses a subset of health care professionals who participate in the Horizon Managed Care Network. This plan also promotes and encourages the use of our patient-centered programs by offering lower member cost share when members preselect and use Primary Care Physicians (PCPs) affiliated with PCMHs and ACOs.

Members only have benefits when they select and use a PCP who participates with the Horizon Medicare Blue Patient-Centered w/Rx (HMO) plan. Members have no benefits for services rendered by providers who do not participate with this plan. And since PCP selection is required, members have no benefits for services provided by a non-preselected PCP who may participate with the Horizon Medicare Blue Patient-Centered w/Rx (HMO) plan.

Advance Physician Search capabilities within our Doctor & Hospital Finder allow users to search specifically for PCPs who participate with the Horizon Medicare Blue Patient-Centered w/Rx (HMO) product as well as those affiliated with one of our established PCMH or ACO practices.

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Member Cost Sharing

Members are encouraged to use PCPs affiliated with one of our patient-centered programs.

  • Members incur the lowest PCP cost-sharing responsibility when they select and use a PCP affiliated with one of our participating PCMH and/or ACO practices who participates in the Horizon Medicare Blue Patient-Centered w/Rx (HMO) product.
  • Members incur a higher PCP cost-sharing responsibility when they select and use a PCP who participates in the Horizon Medicare Blue Patient-Centered w/Rx (HMO) product but who is NOT affiliated with one of our participating PCMH and/or ACO practices.
  • Members incur another level of cost-sharing responsibility when they use a specialist who participates in the Horizon Medicare Blue Patient-Centered w/Rx (HMO).

Copayments apply to nonpreventive services. Horizon Medicare Blue Patient-Centered w/Rx (HMO) covers eligible preventive care, screenings and immunizations at 100 percent without any cost sharing (e.g., copayment, coinsurance or deductible amounts) when provided by a physician or other health care professional who participates with the in the Horizon Managed Care Network.

Other copayments

The Horizon Medicare Blue Patient-Centered w/Rx (HMO) also includes copayments for the following services:

  • Short-term physical, speech, occupational and/or cognitive therapy services provided in a freestanding office setting (limited to a combined 30 visits/calendar year).
  • Therapeutic manipulation provided in an office setting (limited to 30 visits/calendar year).
  • Hospital inpatient services.
  • Mental/behavioral health and substance abuse inpatient and partial hospitalization services.
  • Mental/behavioral health outpatient and office services.
  • Skilled nursing care.
  • Ambulatory Surgical Centers
  • Urgent Care Center services.
  • Ambulance services
  • Emergency Room services.
  • Prescription drugs.

Deductible

There is no deductible for the Horizon Medicare Blue Patient-Centered w/Rx (HMO) plan.

Coinsurance

The Horizon Medicare Blue Patient-Centered w/Rx (HMO) plan provides reimbursement at an 80 percent coinsurance rate for many covered services. Please see the Benefits Overview section for more detailed information.

Maximum out of pocket

After a member incurs $6,700 in eligible out-of-pocket expenses, this plan will cover eligible services at 100 percent of our allowance.

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Referrals

Referrals are required for Horizon Medicare Blue Patient-Centered w/Rx (HMO) members who need care from a specialist or facility.

PCPs may only refer to specialists who are also participating with Horizon Medicare Blue Patient-Centered w/Rx (HMO) for their patients to receive coverage.

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Well Care

Horizon Medicare Blue Patient-Centered w/Rx (HMO) covers eligible preventive care, screenings and immunizations at 100 percent without any cost sharing (e.g., copayment, coinsurance or deductible amounts) when provided by a physician or other health care professional who participates with Horizon Medicare Blue Patient-Centered w/Rx (HMO).

 

Members enrolled in Horizon Medicare Blue Patient-Centered w/Rx (HMO) are covered for one routine physical per calendar year.

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Clinical Labs

Laboratory Corporation of America (LabCorp®) is the exclusive provider of clinical laboratory services for members enrolled in Horizon Medicare Blue Patient-Centered w/Rx (HMO).*

Pathology services provided in a hospital setting to members enrolled in Horizon BCBSNJ managed care plans by a practice that participates in the Horizon Managed Care Network are allowed as an exception to the above-described LabCorp exclusivity requirements.

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Prescriptions

Prior authorization may be required. The Horizon Pharmacy program’s pharmacy benefits administrator is Prime Therapeutics LLC (Prime). Please call 1-877-686-6875.

Prescription drugs may be obtained from a retail pharmacy or through home delivery.

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OON Benefits

The Horizon Medicare Blue Patient-Centered w/Rx (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 Patient-Centered w/Rx (HMO) plan does not include BlueCard (out-of-area) benefits (except in the event of an emergency).

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Prior Authorization/Precertification

Certain services/supplies require prior authorization.

  • Prior-authorization requests
    1-888-789-3457 (phone)
    1-877-798-5903 (fax)
  • Home care and/or Home IV infusion
    1-800-492-2580 (fax)
  • Behavioral health and substance abuse
    The Horizon Behavioral HealthSM program administered by ValueOptions of New Jersey, Inc.
    1-800-397-1630.
  • Physical Therapy Unit
    1-800-723-5188 (fax)
  • eviCore National
    Nonemergency Radiology Services, Advanced Imaging Services (AIS) (MRI, CT, PET Scans, Nuclear Medicine including Nuclear Cardiology), Cardiac Imaging Services, Radiation Therapy and Pain Management Services.
    Advanced Imaging Services (AIS): 1-866-496-6200(phone),1-800-637-5204 (fax)
    Cardiac Imaging: 1-866-496-6200(phone),1-888-785-2480 (fax)
    Radiology Program: 1-866-496-6200 (phone),1-800-637-5204 (fax)
    Pain Management: 1-866-241-6603(phone),1-800-649-4548 (fax)
    Radiation Therapy Program: 1-866-242-5749(phone)
  • ICORE Healthcare
    Medical Injectables Program
    1-800-424-4508(phone)

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Reimbursement

Physicians and other health care professionals participating with Horizon Medicare Blue Patient-Centered w/Rx (HMO) will receive Horizon Managed Care Network reimbursement rates for eligible services.

Reimbursement will be made via capitation or fee-for service, depending on the practice.

Reimbursement for Emergency Care

Although there are no out-of-network benefits with Horizon Medicare Blue Patient-Centered w/Rx (HMO), the following rates will apply for out-of-network emergency care rendered in an Emergency Room or an inpatient setting:

  • The physician is participating in Horizon PPO network – reimbursement will be based off the CMS fee schedule.
  • The physician is participating in our Horizon PPO and Horizon Managed Care Networks – reimbursement will be based off the CMS fee schedule.
  • The physician is participating in Horizon Managed Care Network and is nonparticipating in our Horizon PPO Network – Horizon BCBSNJ will hold the member harmless and reimbursement will be based off the CMS fee schedule.

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Participating Physician Responsibilities

Participating network

Members enrolled in Horizon Advance EPO plans:

  • Must use physicians and other health care professionals who participate with Horizon Medicare Blue Patient-Centered w/Rx (HMO). Members have no benefits (except in the event of an emergency) for services provided by a provider that does not participate with the Horizon Medicare Blue Patient-Centered w/Rx (HMO) plan.
  • Must use a participating Horizon Hospital Network facility.

Please use our Doctor and Hospital Finder to locate a physician or other health care professional who participates with Horizon Medicare Blue Patient-Centered w/Rx (HMO).

Referrals

Referrals are required. PCPs may only refer to specialists who are also participating with Horizon Medicare Blue Patient-Centered w/Rx (HMO) for their patients to receive coverage.

Prior Authorization

Certain services require prior authorization (PA). A list of services that require PA is available online.

Prescription Drug Prior Authorization

Certain prescription drugs require prior authorization.

We encourage you to use the NaviNet Drug Authorization tool to quickly and easily submit and manage your drug PAs. To register and for more information, please visit navinet.net/hzdpa.

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 Horizon Medicare Blue Patient-Centered w/Rx (HMO) should be submitted to us 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 820
Newark NJ 07101-0820
Horizon BCBSNJ
PO Box 199
Newark NJ 07101-1609
Facility Horizon BCBSNJ
PO Box 25
Newark NJ, 07101-0025
Horizon BCBSNJ
PO Box 1770
Newark NJ, 07101-0025
Pharmacy Prime Therapeutics
P.O. Box 64812
St. Paul, Minnesota, 55164-0812
Prime Therapeutics
P.O. Box 64812
St. Paul, Minnesota, 55164-0812

Service

Please seek 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 that information and a service reference number that documents your call.

Please call the specialized teams listed below for information and help with authorizations and precertification.

Service area Telephone number
Physician Services 1-800-624-1110
Institutional Services 1-888-666-2535
Prior Authorization Requests 1-888-789-3457
Behavioral Health 1-800-626-2212
Prime Therapeutics 1-877-686-6875
Home care and/or Home IV infusion 1-800-492-2580(fax)
Member Services 1-866-460-4910

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ID Cards

Horizon Medicare Blue Patient-Centered w/Rx (HMO) plan ID cards include a YKO prefix.