Products

Horizon HMO members select a PCP who will either provide the necessary care or refer them to the appropriate specialist or facility. Members receive full benefit coverage when services are provided or referred by their PCP. Except in emergency situations, self-referred services are not covered and there are no out-of-network benefits.

Copayments

Horizon HMO offers various office visit copayments. Check the member's ID card for the copayment amount due for an office visit.

Coinsurance

Some Horizon HMO members are required to pay a coinsurance payment for most services that are not performed in an office setting.

Under Horizon HMO Access plans, members may receive care from Horizon Managed Care Network specialists without a referral. Members enjoy both the benefits of working with a selected PCP and the freedom to coordinate their needs without a referral. Members may not self-refer to PCP-type providers; they must use their preselected PCP.

Copayments

Horizon HMO Access includes various inpatient and outpatient facility copayments and other professional health care services.

Coinsurance

Some Horizon HMO Access members are required to pay a coinsurance payment for most services not performed in an office setting, including Durable Medical Equipment.

Referrals

Horizon HMO Access members may visit participating specialists without a referral. Preapproval is required for some services.

Out-of-Network Benefits

Horizon HMO Access members have no out-of-network benefits.

Our Horizon Direct Access products allow members to visit participating specialists without a referral from a PCP. Horizon Direct Access is similar to a POS product by offering two levels of benefits: in-network and out-of-network.

Members are encouraged to select a PCP to help them access the appropriate medical care; however, it is not required. PCPs are encouraged to refer members to participating physicians and other health care professionals.

Members are responsible for sharing the cost of their health care. For in-network care, this can amount to a basic office copayment, a deductible or coinsurance. Patients who receive care out-of-network pay a higher share of the costs, sometimes including higher deductibles, coinsurance and/or copayment amounts.

No Referrals

This product does not require referrals for in-network professional services. PCPs do not need to complete referrals for the member to receive care from a specialist or facility.

Prior Authorization

Obtain prior authorization when referring a Horizon Direct Access member to an in-network or out-of-network facility for inpatient and outpatient care. By obtaining the authorization, your patient may incur lower out-of-pocket expenses.

In-Network Benefits

To receive the highest level of benefits, members must access care from a participating physician, other health care professional or facility in the Horizon Managed Care Network. When a Horizon Direct Access member receives care from a participating physician, other health care professional or network facility, they are covered at the in-network level of benefits and incur lower out-of-pocket costs.

Out-of-Network Benefits

Out-of-network benefits apply when members do not use a Horizon Managed Care Network physician, health care professional or facility. Members pay a higher share of the costs for out-of-network care, usually including deductible and/or coinsurance amounts.

Help your Horizon Direct Access members save money by encouraging them to receive all medical care and services from our large, comprehensive network of participating physicians, facilities and other health care professionals. This can significantly reduce their out-of-pocket costs and claim submissions and may also increase their satisfaction with your services.

We recognize that there may be instances in which a service is not available in network. If a member's care is coordinated by their PCP and the proper authorization is obtained, eligible and medically necessary out-of-network services may be covered at the in-network level of benefits.

Horizon Direct Access and BlueCard®

Horizon Direct Access is a managed care product. These ID cards display the PPO-in-the-suitcase logo indicating these members have access to PPO physicians and health care professionals when receiving services outside of New Jersey.

SHBP/SEHBP members may select one of four copayment plans:

• NJ DIRECT10
• NJ DIRECT15
• NJ DIRECT1525
• NJ DIRECT2030
• NJ DIRECT2035
• NJ Educators Health Plan
• CWA Unity DIRECT
• CWA Unity DIRECT 2019
• NJ DIRECT
• NJ DIRECT 2019

For these plans, NJ DIRECT will pay the full cost of in-network services (based on our contracted rate), in most cases, after the appropriate member copayment per visit. Services rendered out-of-network are subject to deductible and a percentage of coinsurance based on plan allowance.

• The number in the plan name (10, 15, 1525, 2030 or 2035) refers to the primary and specialty provider office visit copayment.
• NJ DIRECT10 and NJ DIRECT15 have primary and specialty office visit copayments of $10 or $15.
• NJ DIRECT1525 has a primary office visit copayment of $15; specialty office visit copayment is $25.
• NJ DIRECT2030 has a primary office visit copayment of $20; specialty office visit copayment is $30 for adults, but $20 for children. A child is defined as eligible until the end of the year in which age 26 is reached. Once the 26th year is completed, the member is considered an adult (including disabled dependents who have extended coverage).
• NJ DIRECT2035 has a primary office visit copayment of $20; specialty office visit copayment is $35/20% after deductible at an outpatient facility.
• Primary office visit copayments apply to PCPs (internists, general practitioners, family practitioners, pediatricians, PAs, APRNs.)
• Specialty office visit copayments apply to in-network specialist visits including non-routine Ob/Gyn services, short-term therapist visits (occupational therapy, speech therapy, physical therapy, respiratory therapy, and cognitive therapy) and chiropractic visits.
• The NJ Educators Health Plan has a primary office visit copayment of $10; specialty office visit copayment is $15.
• The CWA Plans, the NJ Direct and NJ DIRECT 2019 plans have a primary and specialist copayment of $15.
• The Emergency Room copayment (waived if admitted) varies by plan.
• The appropriate copayment amounts are indicated on the member's ID card.
• In-network behavioral health services may be subject to office visit copayment.

High-Deductible (HD) Health Plans

SHBP members may select one of two high-deductible plans.

• NJ DIRECT HD1500
• NJ DIRECT HD4000

In the High-Deductible Health Plans, all eligible services (except for eligible preventive services) are subject to deductible, coinsurance and out-of-pocket maximums before services will be considered for benefit.

No copayments apply. The plan is combined with a Health Savings Account (HSA) that can be used to pay for qualified medical expenses.

• The number in the plan's name (1500, 4000) refers to the individual deductible, which is doubled for non-single contracts, and is combined for in- and out-of-network medical services and prescription drugs.
• Members are responsible for expenses, in- and out-of-network, up to the deductible.
• After the annual deductible is met, the member is responsible for 80 percent of the contracted rate in-network and 60 percent of the plan allowance out-of-network.
• If eligible expenses reach the out-of-pocket maximum, eligible services will be covered at 100 percent, subject to all provisions of the plan. For more information about NJ DIRECT, visit HorizonBlue.com/SHBP and click Plan Information.

SHBP/SEHBP: Multiple coverages prohibited

A New Jersey state law enacted in 2010 prohibits multiple coverage under the State Health Benefits Program (SHBP) and/or the School Employees' Health Benefits Program (SEHBP). This means:

• If eligible expenses reach the out-of-pocket maximum, eligible services will be covered at 100 percent, subject to all provisions of the plan.
• An employee or retiree cannot be enrolled for coverage as both a subscriber and a dependent under the SHBP and/or SEHBP.
• An employee cannot be enrolled for coverage as an employee and as a retiree under the SHBP/SEHBP.
• Children cannot be enrolled as dependents for coverage under both SHBP/SEHBP covered parents.
• NJ DIRECT members who have coverage under a non-SHBP/SEHBP plan can maintain enrollment in NJ DIRECT and the non-SHBP/SEHBP plan.
• NJ DIRECT10 and NJ DIRECT15 have primary and specialty office visit copayments of $10 or $15.
• NJ DIRECT1525 has a primary office visit copayment of $15; specialty office visit copayment is $25.
• NJ DIRECT2030 has a primary office visit copayment of $20; specialty office visit copayment is $30 for adults, but $20 for children. A child is defined as eligible until the end of the year in which age 26 is reached. Once the 26th year is completed, the member is considered an adult (including disabled dependents who have extended coverage).
• Primary office visit copayments apply to PCPs (internists, general practitioners, family practitioners, pediatricians, PAs, APRNs.)
• Specialty office visit copayments apply to in-network specialist visits including non-routine Ob/Gyn services, short-term therapist visits (occupational therapy, speech therapy, physical therapy, respiratory therapy, and cognitive therapy) and chiropractic visits.
• The Emergency Room copayment (waived if admitted) varies by plan.
• The appropriate copayment amounts are indicated on the member's ID card.
• In-network behavioral health services may be subject to office visit copayment.

OMNIA BRONZE

Our lowest premium Bronze plan offers members the lowest monthly premium but highest out-of-pocket costs compared to other OMNIA Health Plans. Bronze plans, on average, pay for 60 percent of the covered medical expenses; members pay 40 percent.

OMNIA SILVER

Our lowest premium Silver plan offers a mid-level monthly premium and out-of-pocket costs compared to other OMNIA Health Plans. Silver plans, on average, pay for 70 percent of the covered medical expenses; members pay 30 percent. Cost sharing subsidies may be available with this plan.

OMNIA SILVER HSA

In-network behavioral health services may be subject to office visit copayment.

OMNIA SILVER VALUE

Our lowest premium Silver plan offers mid-level monthly premium and out-of-pocket costs compared to other OMNIA Health Plans. Silver plans, on average, pay for 70 percent of the covered medical expenses; members pay 30 percent. Cost-sharing subsidies may be available with this plan.

OMNIA GOLD

Our lowest premium Gold plan offers higher monthly premium and lower out-of-pocket costs compared to other OMNIA Health Plans. Gold plans, on average, pay for 80 percent of the covered medical expenses; members pay 20 percent.

OMNIA PLATINUM

Our lowest premium Platinum plan offers highest monthly premium and lowest out-of-pocket costs compared to other OMNIA Health Plans. Platinum plans, on average, pay for 90 percent of the covered medical expenses; members pay 10 percent.

Other OMNIA Health Plans

Large group employers, National Accounts, ASOs, Labor Accounts and Public Sector Accounts that select OMNIA Health Plans will have the ability to customize their OMNIA Health Plan benefits programs to include a range of benefit options, including BlueCard® coverage and variations in Tier 2 out-of-pocket costs.

OMNIA Tier Status

All Horizon Managed Care Network physicians, other health care professionals and in-network hospitals are participating with OMNIA Health Plans; however, OMNIA Health Plan members will have lower cost sharing when they use physicians, health care professionals and hospitals with the OMNIA Tier 1 designation.

To make it easier for members to understand their cost sharing responsibilities, all physicians and other health care professionals affiliated with, or who practice under or on behalf of a group practice, will participate with OMNIA Health Plans at the same tier when treating members under a particular group Tax ID Number (TIN).

Ancillary facilities and ancillary professionals that participate in our Horizon Managed Care Network will be designated OMNIA Tier 1. Some exceptions apply.

Visit our Online Doctor & Hospital Finder to review OMNIA Health Plan tier status information.

OMNIA Tier Awareness Administrative Policy

We encourage all participating managed care network physicians and other health care professionals to review our OMNIA Tier Awareness administrative policy.

This policy includes guidelines that participating physicians and other health care professionals are required to follow when they treat, help to coordinate the care of, refer, recommend or advise patients enrolled in OMNIA Health Plans to seek specialty care and/or treatment at a health care facility or hospital.

The guidelines of this policy are designed to help ensure that patients enrolled in OMNIA Health Plans understand the benefit and cost-sharing implications of using physicians, other health care professionals and facilities designated as OMNIA Tier 1 or Tier 2.

To access this policy, registered NaviNet users should log in to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu, and:

• Mouse over References & Resources and select Provider Reference Materials.
• Mouse over Policies & Procedures.
• Select Policies, then Administrative Policies.
• Select Omnia Tier Awareness.

No Out-of-Network Benefits

Members enrolled in OMNIA Health Plans do not have ANY benefits for out-of-network services. OMNIA Health Plan members must use physicians, other health care professionals and hospitals who participate in the Horizon Managed Care Network and the Horizon Hospital Network*, except in cases of medical emergencies.

* OMNIA Health Plans offered to large group employers, National Accounts, ASOs, Labor Accounts and Public Sector Accounts may be customized to include a range of benefit options, including BlueCard® coverage, that are not available in the individual consumer and small employer markets.

Primary Care Physician (PCP) Selection

OMNIA Health Plan members are NOT required to select a Primary Care Physician.

Referrals

Referrals are not required for OMNIA Health Plan members to see a participating Horizon Managed Care Network Specialist.

Prior Authorizations

Prior authorizations are required for certain services.

Preventive Care

Eligible preventive services (physical exams, well-child care, immunizations, etc.) are covered with no member cost-sharing when provided by a doctor or other health care professional participating in the Horizon Managed Care Network.

Cost Sharing

OMNIA Health Plan member cost sharing (copayments, deductibles and coinsurance amounts) will vary based on the type of plan, the place of service and the tier status of the provider of service. Carefully review the OMNIA Health Plan member's Horizon BCBSNJ ID card for the appropriate cost sharing amount.

Laboratory Services

Participating physicians and other health care professionals are required to refer Horizon BCBSNJ patients and/or send Horizon BCBSNJ patient's testing samples to participating clinical laboratories. Failure to comply with this requirement may result in your termination from the Horizon BCBSNJ networks.

Horizon BCBSNJ's Managed Care laboratory network includes Quest Diagnostics in addition to Laboratory Corporation of America® (LabCorp®). LabCorp and Quest provide national in-network clinical laboratory services for your Horizon BCBSNJ managed care patients (i.e., members enrolled in Horizon HMO, Horizon EPO, OMNIA Health Plans, Horizon Direct Access, Horizon POS or Horizon Medicare Advantage plans).

You may refer members enrolled in Horizon PPO and Indemnity plans (and/or send their testing samples to including LabCorp, Quest Diagnostics and/or BioReference Laboratories, Inc., or to one of our other participating clinical laboratories or hospital outpatient laboratories at network hospitals).

As a reminder, our networks include a number of participating laboratories that can provide a variety of specialized laboratory services. To view a full listing of our participating clinical laboratories, visit HorizonBlue.com/doctorfinder and:

• Select Other Healthcare Services from the What are you looking for? menu.
• Select Laboratory – Patient Centers or Laboratory – (Physician Access Only) under the Service Type dropdown menu and click Search.

* 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 LabCorp/Quest network use requirements.

Pharmacy/Prescription Benefits

Each OMNIA Health Plan includes a pharmacy benefit.* OMNIA Health Plan members must use a participating pharmacy. Cost sharing varies based on the plan.

* Large group employers, National Accounts, ASOs, Labor Accounts and Public Sector Accounts have the option to include a pharmacy benefit in their OMNIA Health Plans.

BlueCard® Benefits

Our standard OMNIA Health plans available on and off the Health Insurance Marketplace (exchange) to consumers and small employer groups DO NOT include BlueCard® Benefits. OMNIA Health Plans offered to large group employers, National Accounts, ASOs, Labor Accounts and Public Sector Accounts may be customized to include a range of benefit options, including BlueCard® coverage.

The PPO-in-a-suitcase logo will be displayed on ID cards of any members enrolled in OMNIA Health Plans that include BlueCard® benefits.

Horizon Advantage Exclusive Provider Organization (EPO) plans provide in-network-only benefits through the Horizon Managed Care Network.

PCP Selection

Members enrolled in Horizon Advantage EPO plans are NOT required to select a PCP.

Referrals

Referrals are NOT required for members to see specialists who participate in the Horizon Managed Care Network.

No Out-of-Network Benefits

Members enrolled in Horizon Advantage EPO plans have NO benefits for out-of-network services. Members enrolled in Horizon Advantage EPO plans must use physicians who participate in our Horizon Managed Care Network (except in the case of medical emergencies).

Members enrolled in Horizon Advantage EPO plans have no benefits for services provided by physicians and other health care professionals participating in the Horizon PPO Network.

BlueCard® Program Access

Certain employer groups may choose to provide their members with access to the BlueCard® PPO program. If a member's Horizon Advantage EPO ID card includes the: PPO-in-the-suitcase logo or the empty-suitcase logo, they have access to the BlueCard® PPO program for services provided outside New Jersey.

The PPO-in-the-suitcase logo identifies a member who has benefits for medical services received outside Horizon BCBSNJ's service area. It does not mean these members can see a participating Horizon PPO Network physician or other health care. professional. Horizon Advantage EPO plans must use physicians that participate in the Horizon Managed Care Network (except in the case of medical emergencies.)

The Horizon Patient-Centered Advantage EPO plan is offered to employer groups and provides in-network only benefits through the Horizon Managed Care Network. This plans builds upon our patient-centered programs, which include our Patient-Centered Medical Home (PCMH) and Accountable Care Organization (ACO) programs.

Our Horizon Patient-Centered Advantage EPO plan is similar to our other Horizon Advantage EPO plans, except this plan uses different member cost sharing levels to encourage enrolled members to select and use a Primary Care Physician (PCP) affiliated with one of our established PCMH and/or ACO practices. Horizon Patient-Centered Advantage EPO members incur a lower out-of-pocket expense when they select and use a PCP who participates in one of our patient-centered programs. No PCP selection is required. However, members pay less out of pocket when they select and use a PCP who participates in our patient-centered programs.

Referrals

Referrals are not required for members to see specialists who participate in the Horizon Managed Care Network. Preventive services, screenings and immunizations are covered with no member cost sharing when services are received from an in-network provider. Except in the case of medical emergencies, members have no benefits for out-of-network services.

Referrals are not required to see specialists. Members must use LabCorp for laboratory services. Member cost sharing for primary care and specialist visits vary for each plan. Please confirm specific benefits for members enrolled in each Horizon Patient-Centered Advantage EPO plan.

No Out-of-Network Benefits

All hospitals in the Horizon Hospital Network are considered in-network for Horizon Advantage EPO plans. Reimbursement is paid at the managed care fee schedule.

Horizon BCBSNJ offers innovative Consumer-Directed Healthcare (CDH) products that incorporate a Health Savings Account (HSA) with a high-deductible medical plan. In addition, Horizon BCBSNJ provides a wide variety of tools and resources to help your patients make their health care decisions.

Key Features of CDH Plans

Copayments - Physicians, other health care professionals and facilities should collect copayments during visits (if applicable). Copayment information will appear on the member's ID card. You should wait until you receive an Explanation of Payment (EOP) from Horizon BCBSNJ before billing patients for coinsurance and deductible.

No referrals required for specialists - This reduces the administrative process for you and members.

Individual spending accounts - Horizon MyWay plans are combined with individual spending accounts, such as Health Savings Accounts (HSAs), Health Reimbursement Arrangements (HRAs) and Flexible Spending Accounts (FSAs).

Members can draw from these accounts to pay for medical expenses not covered by their health plan, including deductibles and coinsurance. The member's ID card will indicate whether a member has a HRA or HSA. Members without a card can pay online or through the Horizon MyWay mobile app, which offers a range of tools to help them manage their health spending and supplemental accounts.

Preventive care – Generally, to promote wellness, routine preventive care services that are coded as such are covered at 100 percent. This includes childhood immunizations. The following services are examples of preventive care:

• – Periodic health evaluations, including tests and diagnostic procedures ordered in connection with routine examinations, such as annual physicals
• – Routine prenatal and well-child care
• – Child and adult immunizations
• – Tobacco cessation programs
• – Obesity/weight-loss programs
• – Age-specific screenings

Horizon MyWay – Direct Access Plan Design

The Horizon MyWay Direct Access product combines a high-deductible Horizon Direct Access plan with a spending/savings account. This health plan offers in- and out-of-network benefits and covers preventive care at 100 percent in-network.

Members maximize benefits by using participating managed care physicians, other health care professionals and participating facilities. You can identify Horizon MyWay HRA/HSA Direct Access members by the following ID card prefixes:

• JGB
• JGE
• JGH

Horizon MyWay – PPO Plan Design

The Horizon MyWay PPO product combines a high-deductible PPO plan with a medical account. This health plan offers in- and out-of-network benefits and covers preventive care at 100 percent in-network. Members can maximize benefits by using participating PPO physicians, health care professionals and participating facilities.

You can identify Horizon MyWay HRA/HSA PPO members by the following ID card prefixes:

• JGA
• JGD
• JGG

Horizon MyWay – HMO Access Plan Design

The Horizon MyWay HMO Access product combines a high-deductible Horizon HMO Access plan with a spending/savings account. This health plan offers in-network-benefits only and covers preventive care at 100 percent. Members must use participating managed care physicians, other health care professionals and contracting facilities.

You can identify Horizon MyWay HSA HMO Access members by the following ID card prefix:

• YHH

The New Jersey State Health Benefits Program (SHBP) and the School Employee's Health Benefits Program (SEHBP) committees offer enrolled members access to two high-deductible plans designs: NJ DIRECT HD1500 and NJ DIRECT HD4000. These plans offer in- and out-of-network benefits and include $0 copayments for preventive care services. Members maximize benefits by using participating managed care physicians, other health care professionals and participating facilities. You can identify NJ DIRECT HD1500 and NJ DIRECT HD4000 members by the following ID card prefix:

• NJX

The Horizon Access HSA plans combine our Exclusive Provider Organization plan with either a Health Savings Account (HSA). These plans provide in-network-only benefits through the Horizon Managed Care Network. Members enrolled in Horizon Advantage EPO plans are NOT required to select a PCP and referrals are not required for members to see specialists who participate in the Horizon Managed Care Network. You can identify Horizon Access HSA members by the following ID card prefixes:

• JGR
• JGS
• JGT

Horizon POS is a point-of-service program providing the advantages of a HMO, but incorporating patient cost sharing and an option for members to access care from any physician without a referral from their PCP, at a lower level of benefits.

Horizon POS has two levels of benefits: in-network and out-of-network. To receive the highest level of benefits, members must access care through their PCP (and obtain referrals as appropriate). When member's care is not coordinated through their PCP, the lower, or out-of-network, benefits apply. Members are given the choice to seek services either in-network or out-of-network at each point of service.

Members are responsible for sharing the cost of their health care. For in-network care, this can amount to a basic office visit copayment, a deductible and/or coinsurance. Patients who go out-of-network or see a specialist without a PCP referral pay a higher share of the costs, including higher deductibles, coinsurance and copayment amounts.

Employers or association groups select the level of cost sharing for their employees. Horizon POS is designed to encourage members to maximize their benefits by using their PCP. When Horizon POS members who have not selected you as their PCP come to you without a referral, you should bill us first. We will provide you with an Explanation of Payment (EOP) advising you of our reimbursement and the amount you can collect from your patient.

Routine Lab Tests

All routine lab tests must be performed by Laboratory Corporation of America® (LabCorp) or Quest Diagnostics. STAT laboratory testing in the outpatient department of a hospital requires prior authorization.

• BCBS Service Benefit Plan (FEP PPO)
• BlueCard® PPO
• Horizon Advantage PPO
• Horizon High Deductible PPO Plan D
• Horizon PPO

Indemnity

• Basic Blue℠ Plan A
• BlueCare®
• Comprehensive Health Plan
• Comprehensive Major Medical
• Horizon Basic Health Plan A
• Horizon Basic Plan A/50
• Horizon Comprehensive Health Plan A
• Horizon High Deductible Plan C
• Horizon High Deductible Plan D
• Horizon MSA Plan C
• Horizon MSA Plan D
• Horizon Traditional Plan B, C, D
• Major Medical
• Medallion
• Network Comprehensive Major Medical
• Wraparound

Fixed Fee

• Medical/Surgical Fixed Fee 14/20 Series
• Medical/Surgical Fixed Fee 500 Series
• Medical/Surgical Fixed Fee 750 Series
• Student Program

Consumer-Directed Healthcare (CDH)

• Horizon MyWay HRA
• Horizon MyWay HSA

The Federal Employee Program® (FEP®) is a fee-for-service plan (with standard, basic and focus options) with a preferred provider organization that is sponsored and administered by the Blue Cross and Blue Shield Association and participating Blue Cross and/or Blue Shield Plans.

FEP is a traditional type of plan that encourages members to use Preferred or in-network physicians, other health care professionals and facilities to receive the highest level of benefits. FEP® members may be identified by their unique ID card. Member ID numbers include an R prefix and eight digits.

Plan highlights include:

• PPO reimbursement levels.
• Referrals are not required.
• Some services may require prior authorization.

Standard Option

Members have the freedom to receive covered services from both Preferred and Nonpreferred health care professionals, hospitals and facilities. Members who have the Standard Option have a calendar year deductible, and services are subject to a copayment or coinsurance. The annual deductible is $350 per person/$700 per family. Routine care provided by a preferred health care professional is covered in full. Office visits for:

• PCP/other health care professional preferred: $25 copayment. Specialist preferred: $35 copayment.
• Specialist nonpreferred: Subject to deductible and 35 percent of plan allowance plus difference between plan allowance and billed charge.
• Lab, X-ray and other diagnostic tests preferred: Subject to deductible and 15 percent coinsurance. Nonpreferred: Subject to deductible and 35 percent of plan allowance plus difference between plan allowance and billed charge.
• Preventive Care adult and children preferred: No member liability. Non-Preferred: Subject to deductible and 35 percent coinsurance plus any difference between the allowance and the billed charge.
• Maternity professional care preferred: No member liability. Nonpreferred: Subject to deductible and 35 percent coinsurance plus any difference between the allowance and the billed charge.
• Physical, occupational, speech therapies:
  • 75-visit annual limit for anyone or a combination of all three.
  • $20 copayment per visit. Nonpreferred: Subject to deductible and 35 percent of plan allowance plus any difference between plan allowance and billed charge.
• Surgery preferred: Subject to deductible then 15 percent of Plan allowance. Nonpreferred: Subject to deductible and 35 percent of plan allowance plus any difference between plan allowance and billed charge.
• Inpatient hospital preferred: $350 per admission copayment, unlimited days. Nonpreferred: $450 per admission copayment, 35 percent of allowance and any difference between allowance and charge.
• Outpatient hospital (medical/surgery) preferred: Subject to deductible and 15 percent coinsurance. Nonpreferred: Subject to deductible and 35 percent of plan allowance plus any difference between allowance and charge.

Basic Option

Member's benefits are limited to care performed by Preferred health care professionals, hospitals and facilities, except in certain situations, such as emergency care.

With the Basic Option, members do not have a calendar year deductible; however, most care under the Basic Option is subject to a copayment amount. Routine care provided by a preferred health care professional is covered in full.

Office visits for:

• PCP or other health care professional office visit: $30 copayment.
• Specialist office visit: $40 copayment.
• Blood tests, EKG, Lab tests, pathology services Preferred: $0.
• EEG/Ultrasound/X-rays preferred: $40 copayment.
• Bone density, CT scans, MRI/Pet scans preferred: $100 copayment.
• Preventive care adult and children preferred: $0.
• Maternity professional care preferred: No member liability, inpatient $175 copayment.
• Physical, occupational, speech therapies: 50 visit limit any one or combination of all three.
• Preferred PCP or other health care professional office visit: $30 copayment.
• Surgery preferred: $150 in office setting, $200 in non-office setting
• Inpatient hospital preferred: $175 per day copayment, up to $875 per admission for unlimited days.
• Outpatient hospital (medical/surgery) preferred: $100 copayment, per day, per facility.

For more information about FEP plans, call 1-800-624-5078 or visit fepblue.org.

FEP Blue Focus

This product is designed for federal employees who are:

• Low utilizers of health care services
• Not planning any inpatient stays and/or major surgeries
• Use mostly generic medications
• Managing their chronic conditions

Federal employees who choose FEP Blue Focus must stay in-network and do not need referrals for specialty care.

• Primary Care Physician/Specialists: $10 per visit for your first 10 primary and or specialty care visits.
• Urgent Care $25 copay
• Inpatient hospital, Outpatient hospital and Surgery: 30% of our allowance
• ER (medical emergency): 30% of our allowance
• Lab work (such as blood tests): $0 for the first 10 specific lab tests
• Diagnostic services (such as sleep studies, X-rays, Cat scans): 30% of our allowance
• Just as with the Standard and Basic Options, precertification of inpatient hospital stays is required.
• Limited benefits and additional services that will require prior authorization such as high-tech radiology services (MRI, CT/PET scan). Bariatric surgery must be performed at a facility designated as a Blue Distinction Center for Comprehensive Bariatric Surgery.

Enrollment codes

• 131 FEP Blue Focus - Self Only
• 133 FEP Blue Focus - Self Plus One
• 132 FEP Blue Focus - Self and Family

FEP Inquiry/Claim Submission:

Providers should submit claims electronically through NaviNet or through their vendor using Payer ID 22099. If necessary, inquiries or claims may be mailed to:

These plans are available to employer groups of two to 50 employees under the Small Employer Insurance Reform Act.

Brief benefit description:

• Deductible $250.
• Coinsurance Inpatient services 80%; other care 50%.
• Office Visits/Medical Care Covered after deductible.
• Well Child Care/ Covered. Adult Physicals
• Lab and X-ray Varies with contract.

These plans are available to individuals under the Individual Health Insurance Reform Act.

Brief benefit description:

• Deductible Ranges from $1,000 to $2,50 (Individual); $2,000 to $5,000 (Family).
• Coinsurance Varies 80/20%, 70/30%, 60/40%.
• Office Visits/Medical Care Covered after deductible.
• Well Child Care/ $300 annually per Adult Physicals covered person (except newborns). $500 maximum for newborns up to age 1 year. Not subject to deductible or coinsurance.
• Lab and X-ray Covered after deductible.
• Maternity Related Requires subscribers and/or physicians and other health care professionals to notify us within 12 weeks of medical confirmation of pregnancy. If we are not notified, payment of maternity claims will be reduced by 50 percent.

Basic Blue Plan A is no longer sold by Horizon BCBSNJ; however, we continue to serve those customers currently enrolled. This limited hospitalization plan covers 30 days of inpatient care and some professional services. The plan does not provide benefits for behavioral health and substance use disorder care services.

Brief benefit description:

• Deductible $100/Individual, $300/Family.
• Coinsurance 50/50%.
• Office Visits/Medical Care Covered after deductible.
• Well Child Care/ Covered. Adult Physicals
• Lab and X-ray Covered after deductible.

BlueCare is no longer sold by Horizon BCBSNJ; however, we continue to serve those customers currently enrolled.

Brief benefit description:

• Deductible $500; two deductibles per family.
• Coinsurance 80/20%.
• Office Visits/Medical Care Covered after deductible.
• Well Child Care/ Not covered. Adult Physicals
• Lab and X-ray Covered after deductible.

This plan is no longer sold by Horizon BCBSNJ; however, we continue to serve those customers currently enrolled.

Brief benefit description:

• Deductible Ranges from $100 to $1,000.
• Coinsurance 80/20%.
• Office Visits/Medical Care Covered after deductible.
• Well Child Care/ Not covered. Adult Physicals
• Lab and X-ray Covered after deductible.

Brief benefit description:

• Deductible Ranges from $100 to $1,000.
• Coinsurance Varies 80/20%, 70/30%.
• Office Visits/Medical Care Covered after deductible.
• Well Child Care/ Call Physician Adult Physicals Services for patient benefits if no indication appears on ID card.
• Lab and X-ray Covered after deductible.

Brief benefit description:

• Deductible $1,000, $2,500, $5,000 or $10,000 (Individual); $2,000, $5,000, $10,000 or $20,000 (Family).
• Coinsurance 50/50%.
• Office Visits/Medical Care Covered after deductible.
• Well Child Care/ Covered. Adult Physicals
• Lab and X-ray Covered after deductible.

Brief benefit description:

• Deductible Ranges from $100 to $1,000.
• Coinsurance Varies 80/20%, 70/30%.
• Office Visits/Medical Care Covered after deductible.
• Well Child Care/ Call Physician Adult Physicals Services for patient benefits if no indication appears on their ID card.
• Lab and X-ray Covered after deductible.

Series 14/20

Effective January 1, 2021, Horizon BCBSNJ will introduce Braven Health Plans.
Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) has partnered with Hackensack Meridian Health to form Healthier New Jersey Insurance Company d/b/a Braven Health.
Braven Health, an affiliate of Horizon BCBSNJ, will offer affordable Medicare Advantage health plans with access to the Horizon Hospital Network and the Horizon Managed Care Network. Braven Health individual plan options will be offered to New Jersey's Medicare-eligible population who reside in Bergen, Essex, Hudson, Middlesex, Monmouth, Ocean, Passaic and Union counties. Braven Health members may also live in other counties if they are enrolled through their employer.

• $0 PCP copay; $20 specialist copay
• Prescription drug coverage is included.
• Chiropractor services
• Braven Medicare Plus HMO $20
• Braven Medicare Choice PPO $20 INN /$30 OON
• Braven Medicare Freedom PPO $20 INN /30% OON

Braven Health Participation

Your network participation status with Braven Health plans will be the same as your participation status in the Horizon Managed Care Network or the Horizon Hospital Network.

If you participate in the broad Horizon Managed Care Network, you are participating with:

• Braven Medicare Choice (PPO)
• Braven Medicare Freedom (PPO)
• Braven Medicare Group (HMO-POS)
• Braven Medicare Access Group (HMO-POS)

If you participate in the subset of the Horizon Managed Care Network, you are participating with:

• Braven Medicare Plus (HMO)

The subset used by the Braven Medicare Plus (HMO) plan is the same subset used for our existing Horizon Medicare Blue Advantage plans.

Overall Braven Health will not create significant administrative changes for participating providers.

• Braven Health will follow Horizon BCBSNJ's policies and procedures, including its medical policies.
• Horizon BCBSNJ will provide back-office operations, including network management, claims, customer service and provider services required to operate a Medicare Advantage plan.
• Braven Health will have its own Payer ID 84367. All trading partners and direct submitters will need to register for Braven Health EDI prior to January 1, 2021.

The Horizon Medicare Blue Select (HMO-POS) plan is offered to Medicare-eligible beneficiaries who reside in Union County. Horizon Medicare Blue Select (HMO-POS) members who are in this individual plan will have access to a subset of the Horizon Managed Care Network in New Jersey. The plan offers in-network and out-of-network benefits and does require a PCP selection. Members do not need referrals. In-network level of benefits are available when members obtain services from participating physicians and hospitals.

Copayments and Coinsurance

Our Medicare Advantage plans offer various office visit copayments. In other health care settings, coinsurance may be required. Copayment amounts and coinsurance percentages, if applicable, are printed on the member's ID card.

Audiology/Hearing Aid Benefits

Audiology Distribution, LLC, doing business as HearUSA, works with Horizon BCBSNJ to administer hearing benefits and provide related products and services through their HearUSA network of independently practicing audiologists, hearing care professionals and company-owned hearing centers.

Members Enrolled in MA Plans with No Out-of-Network Benefits

Members enrolled in Horizon Medicare Blue Value (HMO), Horizon Medicare Blue Value w/Rx (HMO), Horizon Medicare Blue Choice w/Rx (HMO) and Horizon Medicare Blue Advantage (HMO) must use a HearUSA Center for audiology services and hearing aids that are medically necessary, including batteries.

If these members reside in a New Jersey county without a HearUSA Center, they may request that their Primary Care Physician (PCP) refer them to a participating Horizon Managed Care Network audiologist. These same members who reside in a New Jersey county without a HearUSA Center will be reimbursed directly for hearing aids/batteries supplied by any non-HearUSA provider.

Members enrolled in MA plans with out-of-network benefits

Members enrolled in Horizon Medicare Blue Access Group (HMO-POS) and Horizon Medicare Blue Access Group w/Rx (HMO-POS) may use a HearUSA Center for in-network audiology services and hearing aids, including batteries, that are medically necessary.

If these members choose to use their out-of-network benefits (understanding that they will incur more cost sharing), they may obtain services from a non- HearUSA provider. If these members reside in a New Jersey county without a HearUSA center, they may use any participating Horizon Managed Care Network audiologist on an in-network basis. These same members who reside in a New Jersey county without a HearUSA center will be reimbursed directly for hearing aids/batteries supplied by any non-HearUSA provider.

To locate a HearUSA Center., visit HorizonBlue.com/doctorfinder, select Other Health Services tab and:

• Select Audiology within the Service Type menu.
• Enter your ZIP code and indicate a Search Radius, or select your County, then click Search.

Emergency and Urgent Care Definitions

For our Medicare Advantage products, a medical emergency is a medical condition manifesting itself by acute symptoms of sufficient severity (including, but not limited to, severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child, (b) Serious impairment of bodily functions, or (c) Serious dysfunction of any bodily organ or part.

Emergency services include a medical screening examination and inpatient and outpatient services that are needed to stabilize an emergency medical condition.

For our Medicare Advantage products, urgently needed services are those services required to prevent a serious deterioration of a covered person's health that results from an unforeseen illness, injury or condition that requires care within 24 hours.

According to the Centers for Medicare & Medicaid Services (CMS), all information included within a medical record must be legible for review by an approved CMS coder and must include the following information to document a face-to-face encounter.

• The physician or other health care professional must authenticate the services provided or ordered by including either a hand-written or electronic signature along with his/her credentials. The following types of signatures are not acceptable:
  • Stamp signatures
  • Signature of a physician other than the treating physician
  • Signature of a nurse or other office professional on the physician's behalf
  • Statements that indicate: Signed but not read; Dictated but not signed/read; etc.
• The medical record should include sufficient information to ensure that a reviewer can determine the date on which a particular service was performed/ordered.
• The medical record should include sufficient documentation to support the diagnoses billed.
• Each page of a medical record must include the patient's name. The official instruction (Change Request 6698) may be accessed at cms.gov/Transmittals/downloads/R327PI.pdf.

Medical Record Retention

Physicians and other health care professionals are required to maintain medical records for a minimum of 10 years for all Medicare Advantage members.

The medical necessity review and determination process for Horizon Medicare Advantage products is different than that of other managed care products. If you or the member disagrees with a coverage determination we have made, the decision may be appealed. We have up to 14 days to determine whether an initial request for a service is medically appropriate and covered. If additional clinical information is required, we may have up to an additional 14 days to make a determination.

In some cases, the standard pre-service review process could endanger the life or health of the member. As a participating physician or other health care professional, you may request an expedited 72-hour pre-service determination for a Medicare Advantage patient if, in your opinion, the health or the ability of your patient to function could be harmed by waiting for a medical necessity determination. Request expedited determinations by calling 1-800-664-BLUE (2583).

Medicare Part D Prescription Drug Determinations

Requests for a coverage determination will be responded to within 24 hours for an expedited request (or sooner if the member's health requires us to) or within 72 hours for a non-expedited coverage determination. Part D drug coverage determinations include:

• Prior authorization determinations for those drugs that require prior authorization.
• Requests that we cover a Part D drug that is not on the plan's List of Covered Drugs (Formulary).
• Requests that we waive a restriction on the plan's coverage for a drug, including:
  • Being required to use the generic version of a drug instead of the brand name drug.
  • Being required to try a different drug first before we will agree to cover the drug you are asking for. (This is sometimes called step therapy.)
  • Quantity limits. For some drugs, there are restrictions on the amount of the drug patients can have.
• Requests that we pay for a prescription drug the member already purchased (a coverage decision about payment). Request expedited Medicare Part D by calling 1-800-693-6651. Non-expedited Medicare Part D drug determinations may be requested in writing to:
  Prime Therapeutics LLC
  Attn: Medicare Appeals Department
  1305 Corporate Center Drive
  Bldg N10
  Eagan, MN 55121
  Fax: 1-800-693-6703

Horizon Medicare Advantage Member Appeals

Members have the right to appeal any decision regarding our reimbursement or our denial of coverage based on medical necessity. Appeals may be requested verbally or in writing. Medical records and your professional opinion should be included to support the appeal.

Based on the medical circumstances of the case, a Horizon BCBSNJ physician reviewer will determine if the request qualifies as an expedited appeal. However, the member, physician or other authorized representative acting on behalf of the member may request an expedited appeal based on the medical circumstances of the case.

If coverage of services is denied, you must inform your Medicare Advantage patient of their appeal rights. At each patient encounter with a Medicare Advantage enrollee, you must notify the enrollee of their right to receive, upon request, a detailed written notice from the Medicare Advantage organization regarding the enrollee's benefits. You may issue the appeal rights directly to the member in your office at the time of the denial, or contact Member Services and we will issue the appeal rights to the member. Details about how to pursue various appeals and appeal levels will be communicated in writing as part of each coverage determination and/or appeal determination notification.

Medical Appeals for Medicare Services

Generally, we have 30 days to process an appeal pertaining to denial of a requested service (pre-service appeal for service), and 60 days to process an appeal pertaining to post-service denial of claim payment (appeal for payment). Expedited appeals are processed within 72 hours. To file an expedited appeal, the member may call Member Services at +1-800-365-2223.

A completed Appointment of Representative (AOR) form or other court-appointed document indicating the member's consent may be required for a physician to pursue post-service appeals on behalf of the member.

Medicare Part D Prescription Appeals

Generally, we have up to seven days to process an appeal pertaining to a post-service denial of coverage decision or claim for a Medicare Part D prescription drug and up to 72 hours to process an appeal pertaining to a coverage decision of a Medicare Part D prescription drug the member has not yet received. Expedited appeals are processed within 24 hours.

To file an expedited Medicare Part D appeal, the member may call 1-800-693-6651. To request a Medicare Part D prescription drug appeal in writing, members may fax to 1-800-693-6703 or write to:

Subcontractors and Medicare

Participating offices that have entered into business arrangements with a subcontractor must ensure that all contracts with those entities include language that requires them to comply with all applicable Medicare laws and regulations.

Nine-Digit ZIP Codes Required for Claim Submissions

CMS requires the use of nine-digit ZIP codes on all Medicare Advantage claim submissions in certain locations where a five-digit ZIP code spans more than one pricing area. The New Jersey, New York and Pennsylvania towns that require the use of nine-digit ZIP codes are listed below.

To avoid delays in claim processing, we recommend that physicians and other health care professionals within these areas bill with the complete nine-digit ZIP code for all patients. If you're unsure of your nine-digit ZIP code, visit the United States Postal Service's online ZIP Code Lookup at usps.com/zip4.

We offer a variety of Medicare Supplemental Products to our members who have Original Medicare as their primary insurance coverage.

As of January 1, 2020:

Horizon Medicare Blue Supplement Plans C and F, which pay the Medicare Part B deductible, are no longer sold to the following individuals:

• Age 65+: individuals who turn age 65 on or after January 1, 2020.
• Under Age 65: individuals whose Medicare Part B effective date is on or after Plan availability is now based on the following criteria:
  • In the Age 65+ market, whether the applicant turned 65 before January 1, 2020, or on/after January 1, 2020.
  • In the Under Age 65 market, whether the applicant's Part B effective date is before January 1, 2020, or on/after January 1, 2020.
• For the Age 65+ market, Horizon Medicare Blue Supplement Plan G is now available with any of the Guaranteed Issue Rights.
• For the Under Age 65 market, the enrollment opportunities have been revised, with the most notable being that persons who have a Part effective date on or after January 1, 2020 have 12 months from their Part B effective date (rather than 6 months) to enroll.

Horizon Medicare Blue Supplement Plan D

Available for the Age 65+, Age 50 to 64 and Under Age 50 markets. These Medigap products supplement or fill the gaps of eligible services paid by Medicare and have also been referred to as complementary coverage in the past.

Horizon Contemporary Medigap Plans

As required by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), we offer this set of standardized Medigap plans. These plans, to distinguish them from the previously offered Medigap plans (which we continue to service, but no longer sell), are identified by a YHW prefix on their ID card and are referred to as Horizon Contemporary Medigap Plans.

We offer the following Horizon Contemporary Medigap Plans:

• Plan A
• Plan C – ages 50 to 64
• Plan C – age 65+
• Plan C – under age 50
• Plan F
• Plan G
• Plan K
• Plan N

For more information about Horizon Contemporary Medigap Plans, visit HorizonBlue.com/medicare. Horizon Contemporary Medigap Plans are the only Medigap plans we offer for sale.

For members enrolled in one of our existing Medigap plans (see below), there will be no change in benefits. However, members may choose to enroll in one of the new Horizon Contemporary Medigap Plans, as long as they meet the requirements for that new plan.

• Horizon Medigap Plans A
• Horizon Medigap Plan C
• Horizon Medigap Plan F
• Horizon Medigap Basic Plan I
• Horizon Medigap Plan I with Rx
• Horizon Medigap Plan J
• BCBSNJ 65
• BCBSNJ 65 Select
• Super 65

Members enrolled in the above Medigap plans are identified by a YHR prefix on their ID card.

Medicare Part D

We also offer Medicare Part D Prescription Drug coverage to our members who have Original Medicare as their primary insurance coverage.

Pre-Existing Condition

Medigap plans include a pre-existing condition clause. Under this clause, claims for certain members, may be subject to review. A pre-existing condition is an illness or injury, whether physical or mental, which manifests itself in the six months before a covered person's enrollment date, and for which medical advice, diagnosis, care or treatment would have been recommended or received in the six months before his/her enrollment date.

The restriction could remain on the member's policy as noted below unless a Certificate of Creditable Coverage (COCC) is provided. (A COCC, or a letter from a previous carrier on that carrier's letterhead indicating the effective and terminating dates of coverage, will nullify or reduce the pre-existing wait period.)

• For beneficiaries age 65 and over, the pre-existing condition limitation waiting period is six months from the date of enrollment.
• For beneficiaries under age 65, the pre-existing condition limitation waiting period is three months from the date of enrollment.

Based on the member's pre-existing limitation clause under the benefit plan, review of claims in excess of $10,000.00 will be conducted to determine if a pre-existing condition exists. If a pre-existing condition exists, the member will be responsible for payment of services rendered.