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For more information about Horizon Behavioral Health, visit www.horizonblue.com/shbp or call the Behavioral Health Services number on the back of your Horizon HMO ID card.

Prior Authorization Prior authorization is the approval Horizon HMO gives you and your participating physician prior to receiving certain specialty services. With the proper prior authorization, your specialty services will be covered under your Horizon HMO plan. Prior authorization is also known as pre-approval.

When You Need Prior Authorization Prior authorization may be required for some hospital-related care, some outpatient services and some durable medical equipment (DME). If you have questions about which services need prior authorization under your Horizon HMO, please speak with your physician or other health care professional. If you still have questions regarding prior authorization, please contact your dedicated SHBP/SEHBP customer service area at 1-800-414-7427 (SHBP).

When Your Physician Requests Prior Authorization When you need hospital care or services, your participating physician will coordinate your prior authorization with Horizon HMO. Once your physician authorizes your care with Horizon HMO, he/she will be given a prior authorization number.

Utilization Management (Medical Management and Review) Treatment is subject to Utilization Management (UM), a process used to ensure that treatment is medically needed and provided at the appropriate level of care. Your network provider is responsible for the UM contact. Benefits are payable for treatment when they are provided by an in-network provider, the UM organization has been notified to review the treatment, and the UM organization has approved the treatment.

The Horizon HMO adheres to the following UM principles. The Horizon HMO:

1. Makes UM decisions based solely on the necessity and appropriateness of care and services within the parameters of the member’s benefit package.

2. Does not compensate those responsible for making UM decisions in a manner that incents them to deny coverage for medically necessary and appropriate covered services.


3. Does not offer incentives to those responsible for UM determinations to encourage denials of coverage or services and does not provide financial incentives to physicians to withhold covered health care services that are medically necessary and appropriate.

4. Emphasizes the provisions of medically necessary, appropriate and cost-effective delivery of health care services to members and encourages the reporting, investigation and elimination of underutilization.

Experimental or Investigational Treatments

Horizon HMO does not cover treatment that is considered experimental or investigational. Charges in connection with such a service or supply are also not covered. For the purpose of this exclusion, a service or supply will be considered experimental or investigational if Horizon HMO determines that one or more of the following is true.

1. The service or supply is under study or in a clinical trial to evaluate its toxicity, safety, or efficacy for a particular diagnosis or set of indications. Clinical trials include but are not limited to phase I, II, and III clinical trials, with the exception of approved cancer trials.

2. The prevailing opinion within the appropriate specialty of the United States medical profession is that the service or supply needs further evaluation for a particular diagnosis or set of indications before it is used outside clinical trials or other research

settings. Horizon HMO will determine this based on:

• Published reports in authoritative medical literature; and

• Regulations, reports, publications, and evaluations issued by US government agencies such as the Agency for Health Care Research and Quality, the National Institutes of Health, and the federal Food and Drug Administration (FDA).

3. The provider's institutional review board acknowledges that the use of the service or supply is experimental or investigational and subject to that board's approval.

4. The provider's institutional review board requires that the patient, parent, or guardian give an informed consent stating that the service or supply is experimental or investigational, part of a research project or study, or federal law requires such consent.

5. Research protocols indicate that the service or supply is experimental or investigational. This item applies for protocols used by the patient's provider as well as for protocols used by other providers studying substantially the same service or supply.

6. The service or supply is not recognized by the prevailing opinion within the appropriate medical specialty as an effective treatment for the particular diagnosis or set of indications.

7. Additionally, if it is a drug, device, or other supply that is subject to FDA approval it

will be considered experimental and investigational if it:


• Does not have FDA approval for sale and use in the United States (that is, for introduction into and distribution in interstate commerce); or

• Has FDA approval only under the Treatment Investigational New Drug regulation or a similar regulation; or

• Has FDA approval, but is being used for an indication or at a dosage that is not an acceptable off-label use. Horizon HMO will determine if a certain use is an accepted off-label use based on published reports in peer-reviewed, authoritative medical literature and entries in the following drug compendia: The American Medical Association Drug Evaluations, the American Hospital Formulary Service Drug Information, and the United States Pharmacopoeia Dispensing Information.

Chronic Care Program

The Horizon HMO Chronic Care Program helps members with chronic conditions take better care of their health, understand their care choices and improve their health. This

program is available at no added cost to eligible members with:

☐ Asthma.

☐ Chronic Kidney Disease (CKD).

☐ Chronic Obstructive Pulmonary Disease (COPD).

☐ Coronary Artery Disease (CAD).

☐ Diabetes.

☐ Heart Failure.

For more information:

☐ Visit www.HorizonBlue.com/shbp and click Health Programs under the Health & Wellness tab.

☐ Or, call 1-888-345-1150, Monday through Friday, between 8 a.m. and 7 p.m., Eastern Time. If you are hearing-impaired, please call 1-800-855-2881 during the same hours.

24 — HORIZON HMO MEMBER HANDBOOK Case Management Program If you have a serious health problem or need major surgery, you may be able to sign up for Horizon HMO’s Case Management program. A case manager, who is a registered nurse, can help you understand your treatment choices and find out about available specialists, hospitals, and care, while making sure you get the most out of your Horizon HMO benefits. Your case manager can work with you and your physician(s) to make sure you get the most appropriate and effective treatment.

He/she will also:

•Work with your physician to make sure you know your health problem and treatment choices.

•Handle prior authorization requests for special services, equipment and other supplies as asked for by your physician and other health care professionals.

•Give you information about local services for you and your family.

•Help you get the right care while you are in the hospital and after you leave.

For more information or to sign up, call 1-888-621-5894, option 2, Monday through Friday, between 8 a.m. and 5 p.m., Eastern Time.

This program is available at no added cost to eligible members.


Under the Horizon HMO, care is provided through a network of providers that includes internists, general practitioners, specialists, pediatricians, pharmacies and hospitals.

Care under Horizon HMO must be provided by in-network providers to be covered.

Well-care and preventive services are covered in addition to services for the treatment of illness or injury. Your PCP will coordinate your care and obtain referrals for any specialty care you may require. Referrals are required for visits to a specialist. To find current participating physicians in New Jersey contact Horizon HMO directly at 1-800-414-SHBP or visit: www.horizonblue.com/shbp

–  –  –

Horizon HMO will pay, in most cases, the full cost after the copayment for covered physician office visits. Copayments apply to in-network, provider office visits unless

otherwise indicated and vary by plan option as outlined below:

–  –  –

Depending on the HMO option selected, some services may be subject to deductible and or coinsurance. In-network hospital admissions are covered in full in most cases.

No benefits are available for non-network services. Members accessing urgent care services outside of New Jersey can utilize physicians participating in the national BlueCard® PPO Network.

¹HMO10 is available ONLY to ACTIVE Local Government and Local Education employees and ALL retirees;

²HMO15 is available ONLY to ACTIVE State Employees;

³HMO1525 is available ONLY to ACTIVE Local Education Employees and ALL retirees;

HMO2030 is available ONLY to ACTIVE Local Education Employees and ALL retirees;

HMO2035 is available ONLY to ACTIVE Local Education Employees.

26 — HORIZON HMO MEMBER HANDBOOK In-Network Deductible (Horizon HMO2035 Only) Horizon HMO2035 members must meet a $200 individual or $500 family annual, in-network deductible before in-network charges are paid by the plan. The in-network deductible does not apply to physician office visits that are subject to an office visit copay or emergency room services that are subject to the emergency room copay.

In-Network Coinsurance (Horizon HMO2035 Only) With the exception of physician office visits that are subject to a copayment, HMO2035 members are responsible for twenty percent coinsurance for all in-network services after the in-network deductible has been met. In-network coinsurance paid by the member is applied toward the In-Network Coinsurance out-of-pocket maximum.

Annual In-Network Coinsurance Out-of-Pocket Maximum (Horizon HMO2035 Only) Horizon HMO2035 includes a $2,000 individual and $5,000 family in-network coinsurance out-of-pocket maximum. During the plan year, coinsurance paid by the member accumulates toward the in-network coinsurance out-of-pocket maximum. If the member’s out-of-pocket expenses reach the in-network coinsurance maximum, the member will be in benefit and eligible services will be covered at 100% for the balance of the plan year.

Annual In-Network Out-of-Pocket Maximum The Annual In-Network Out-of-Pocket maximum is the annual limit on the amount of costsharing individuals or families are required to pay for covered health care expenses. Once the annual in-network out-of-pocket maximum per individual or per family is met, Horizon HMO will pay 100 percent of the cost of covered in-network services for the balance of the plan year. For all Horizon HMO options, out-of-pocket expenses paid by the member including copayments, deductible and coinsurance apply toward the annual in-network out-of-pocket maximum. In-network Out-of-Pocket Maximum limits for Horizon HMO are shown in the charts below.

–  –  –

28 — HORIZON HMO MEMBER HANDBOOK Limits / Deductibles Coverage for certain services are subject to limitations. Unless noted otherwise, these limits apply to all HMO options.

• Coverage for physical therapy, speech therapy and occupational therapy is limited to 60 visits per calendar year for all three therapies combined, except that therapy services rendered for a diagnosis of autism or developmental disability will have no limit to the number of visits.

• Coverage for chiropractor visits is limited to 20 per calendar year.

• Private duty nursing coverage is limited to 60 eight-hour shifts. Prior authorization is required. Inpatient private duty nursing is not covered.

• Skilled nursing facility care is limited to 120 days per benefit period.

Some services require the payment of a deductible before eligible charges are covered.

• Horizon HMO, Horizon HMO1525, and Horizon HMO2030 members must meet a $100.00 per person per calendar year deductible for Durable Medical Equipment and Medical Appliances/Equipment.


For group plans that have a Coordination of Benefits (COB) provision, the following rules determine which plan is primary.

• If you, the active employee, are the patient, Horizon HMO is primary for you. If your spouse/partner is the patient, and covered under a health plan provided through his or her employer as an active employee, that plan is the primary plan for them.

• If a member has coverage as an active employee and additional coverage as a retiree, the coverage through active employment is primary to retiree coverage.

• When Medicare is involved (except for ESRD; see page 15), the benefits of the plan that covers an active employee and/or his or her dependents will be considered primary before the benefits of a plan that covers a laid-off or a retired employee and his or her dependents.

• If a dependent child is the patient and is covered under both parents' plans, the following birthday rule will apply.

Under the birthday rule, the plan covering the parent whose birthday falls earlier in the year will have primary responsibility for the coverage of the dependent children. For example, if the father's birthday is July 16 and the mother's birthday is May 17, the mother's plan would be the primary plan for the couple's dependent children because the mother's birthday falls earlier in the year. If both parents have the same birthday, the plan covering the parent for the longer period of time will be primary.


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