Horizon Patient-Centered Advantage EPO Silver and Bronze Plans

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 two new Advantage EPO plans in New Jersey for our Small Group customers:

  • Horizon Patient-Centered Advantage EPO Silver.
  • Horizon Patient-Centered Advantage EPO Bronze.

These new Advantage EPO plans offer lower member cost-sharing levels to encourage enrolled members to preselect and use a Primary Care Physician (PCP) affiliated with one of our established PCMH or ACO practices.

Horizon Patient-Centered Advantage EPO Silver and Bronze plan members incur the lowest out-of-pocket expense when they:

  • Preselect and use a PCP who participates in one of our Patient-Centered programs.

Horizon Patient-Centered Advantage EPO Silver and Bronze plan members incur higher out-of-pocket expense (either a higher copayment amount or a deductible/coinsurance responsibility) when they:

  • Preselect and use a Horizon Managed Care Network PCP who does not participate in one of our Patient-Centered programs.
  • Use a Horizon Managed Care Network primary physician who was not preselected as that member’s PCP.
  • Use a Horizon Managed Care Network specialist.

Other features of our Horizon Patient-Centered Advantage EPO Silver and Bronze plans include:

  • Access to physicians, facilities and other health care professionals within the Horizon Managed Care Network.
  • Optional PCP selection; however, members pay less out of pocket when they select and use a PCP who participates in a Patient-Centered program.
  • No 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.
  • No out-of-pocket benefits are available except in the event of an emergency.

Horizon Patient-Centered Advantage EPO Silver and Horizon Patient-Centered Advantage EPO Bronze plans are not offered to individuals purchasing insurance through the New Jersey Insurance Marketplace.

Learn more about these plans:

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Benefits Overview

Horizon Patient-Centered Advantage EPO Silver Horizon Patient-Centered Advantage EPO Bronze
Network Members must use providers that participate in the Horizon Managed Care Network. Members must use providers that participate in the Horizon Managed Care Network.
Primary Care Physician (PCP) Selection PCP selection is optional; however, members incur lower cost sharing when they preselect and use a PCP affiliated with one of our participating PCMH and/or ACO practices. PCP selection is optional, however, 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 not required. Referrals are not required.
Prior Authorization Certain services/supplies require 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.
Eligible preventive services are covered at 100% with no member cost sharing.
Limited to one routine physical per calendar year.
PCP Office Visit $20 copayment per visit to a preselected PCMH/ACO PCP $40 copayment per visit to a preselected PCMH/ACO PCP
$30 copayment per visit (after the deductible is met) to a preselected Horizon Managed Care Network PCP 50 percent coinsurance (after the deductible is met) to a preselected Horizon Managed Care Network PCP
70 percent coinsurance (after the deductible is met) per visit to a non-selected Horizon Managed Care Network PCP 50 percent coinsurance (after the deductible is met) per visit to a non-selected Horizon Managed Care Network PCP
Specialist Office Visit 70 percent coinsurance (after the deductible is met) per visit to a Horizon Managed Care Network Specialist. 50 percent coinsurance (after the deductible is met) per visit to a Horizon Managed Care Specialist.
Deductible $2,000 individual deductible/$4,000 family deductible. $2,500 individual deductible/$5,000 family deductible.
Chiropractic $30 copayment per visit.
Limited to 30 visits/calendar year.
50 percent coinsurance (after the deductible is met).
Limited to 30 visits/calendar year.
Short-term Therapies
(in an office setting)
$30 copayment per visit.
Limited to a combined 30 visits per calendar year for physical, speech, occupational and cognitive therapies performed in an office setting.
50 percent coinsurance (after the deductible is met).
Limited to a combined 30 visits per calendar year for physical, speech, occupational and cognitive therapies performed in an office setting.
Emergency Room $100 Copayment per visit and 70 percent coinsurance after the deductible is met. $100 copayment per visit and 50 percent coinsurance after the deductible is met.
Inpatient Care 70 percent coinsurance after the deductible is met. $500 copayment per day after the deductible is met.
DME 50 percent coinsurance after the deductible is met. 50 percent coinsurance after the deductible is met.
Hospice Care 70 percent coinsurance after the deductible is met. 50 percent coinsurance after the deductible is met.

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Participating Network

  • Members must use physicians and/or other health care professionals who participate in the Horizon Managed Care Network.
  • Members incur the lowest cost-sharing when they preselect and use a PCP who participates in one of our Patient-Centered programs.
  • Use our Doctor & Hospital Finder to locate a physician, other health care professional or facility that participates in the Horizon Managed Care Network. Advance Physician Search capabilities within our Doctor & Hospital Finder allow users to search specifically for PCPs participating in either our Patient-Centered Medical Home or our Accountable Care Organization programs.

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Primary Care Physician (PCP) Selection

PCP selection is optional for members enrolled in Horizon Patient-Centered Advantage EPO Silver and Bronze plans, however, members incur the lowest cost sharing responsibility when they preselect and use a PCP affiliated with one of our participating PCMH and/or ACO practices.

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Member Cost-Sharing

The following member cost-sharing amounts – the amount a member must pay out of pocket, which includes copayments, deductibles and coinsurance amounts – apply to members enrolled in Horizon Patient-Centered Advantage EPO Silver and Bronze plans.

Copayments

Horizon Patient-Centered Advantage EPO Silver and Bronze plans include copayments for the following services:

Horizon Patient-Centered Advantage EPO Silver:

  • Services* provided by a preselected PCMH/ACO PCP in an office setting.
  • Services* provided by a preselected managed care network PCP (not affiliated with a PCMH/ACO practice).
  • 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).
  • Emergency Room services.
  • Prescription drugs.

Horizon Patient-Centered Advantage EPO Bronze:

  • Services* provided by a preselected PCMH/ACO PCP in an office setting.
  • Hospital inpatient services.
  • Mental/Behavioral health inpatient services.
  • Substance use disorder inpatient services.
  • Delivery and all inpatient services.
  • Rehabilitation services (inpatient).
  • Habilitative services (inpatient).
  • Skilled nursing care.
  • Emergency Room services.
  • Prescription drugs.

* Copayments apply to nonpreventive services. Horizon Patient-Centered Advantage EPO Silver and Bronze plans cover eligible preventive care, screenings and immunizations at 100% without any cost sharing (e.g., copayment, coinsurance or deductible amounts) when provided by a physician or other health care professional who participates in the Horizon Managed Care Network.

Deductibles

Horizon Patient-Centered Advantage EPO Silver and Bronze plans include deductible amounts that must be met before we begin to pay for many covered services. Please see the Benefits Overview section for more detailed information.

Horizon Patient-Centered Advantage EPO Silver:

  • $2,000 Individual
  • $4,000 Family

Horizon Patient-Centered Advantage EPO Bronze:

  • $2,500 Individual
  • $5,000 Family

Coinsurance

Horizon Patient-Centered Advantage EPO Silver and Bronze plans provide reimbursement at a coinsurance rate, a percentage of the allowed amount, for most covered services after the member’s deductible has been met. Please see the Benefits Overview section for more detailed information.

Horizon Patient-Centered Advantage EPO Silver:

  • This plan provides reimbursement at 70 percent of the allowed amount for the most covered services.

Horizon Patient-Centered Advantage EPO Bronze:

  • This plan provides reimbursement at 50 percent of the allowed amount for most covered services.

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Referrals

Referrals are not required for Horizon Patient-Centered Advantage EPO Silver and Bronze plans.

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Well Care

Horizon Patient-Centered Advantage EPO Silver and Bronze plans cover eligible preventive care, screenings and immunizations at 100% without any cost sharing (e.g., copayment, coinsurance or deductible amounts) when provided by a physician or other health care professional who participates in the Horizon Managed Care Network.

Members enrolled in Horizon Patient-Centered Advantage EPO Silver and Bronze plans 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 Patient-Centered Advantage EPO Silver and Bronze plans.*

* 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. Prime Therapeutics is the pharmacy benefits manager of the Horizon Pharmacy Program. Please call 1-888-215-3015.

Prescription drugs may be obtained from a retail pharmacy or through mail order.

Members are responsible for a copayment based upon which of three tiers a particular drug is included:

  • Generic Drugs.
  • Preferred brand drugs.
  • Non-Preferred brand drugs.

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Out-of-Network Benefits

Horizon Patient-Centered Advantage EPO Silver and Bronze plans do not include out-of-pocket benefits (except in the event of an emergency).

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BlueCard® (Out-of-Area) Benefits

Horizon Patient-Centered Advantage EPO Silver and Bronze plans do 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
    1-800-664-2583
    1-877-798-5903 (fax)
  • Home care and/or Home IV infusion
    1-800-492-2580 (fax)
  • Mental health and substance abuse Value Options administers the Horizon Behavioral Health program
    1-800-397-1630
  • Physical Therapy Unit
    1-888-789-3457
    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).
    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.

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Reimbursement

  • Physicians and other health care professionals participating in Horizon Patient-Centered Advantage EPO Silver and Bronze plans will receive Horizon Managed Care Network reimbursement rates for eligible services.
  • There is no capitated reimbursement for services provided to members enrolled in Horizon Patient-Centered Advantage EPO Silver and Bronze plans. All reimbursement will be fee for service.

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Participating Physician Responsibilities

Participating network

Members enrolled in Horizon Patient-Centered Advantage EPO Silver and Bronze plans:

  • Must use physicians and other health care professionals who participate in the Horizon Managed Care Network. Horizon Patient-Centered Advantage EPO Silver and Bronze members have no out-of-pocket benefits (except in the event of an emergency).
  • Must use a participating Horizon Hospital Network facility.

Please use our Doctor & Hospital Finder to locate a physician or other health care professional who participates in Horizon Patient-Centered Advantage EPO Silver and Bronze plans.

Referrals

Referrals are not required.

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 to use the NaviNet Drug Authorization tool or 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 Patient-Centered Advantage EPO Silver and Bronze plans may 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 1609
Newark NJ 07101-1609
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 1-800-664-BLUE (2583)
Horizon Behavioral Health 1-800-397-1630
Prime Therapeutics 1-888-215-3015
Physical Therapy Unit 1-888-789-3457
Member Services 1-866-460-4910

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ID Cards

Patient-Centered Advantage EPO Silver and Bronze plan ID cards include a JGR prefix.

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