about your benefits...7 what do you pay? each insurance plan is different. that’s why...

Silver HSASM

BronzeSM

About Your Benefits

HorizonBlue.com

MEMBER ONLINE SERVICES | MEMBERS.HORIZONBLUE.COM | 24 hours a day, seven days a week2

Welcome!This handbook is designed to make

understanding your health insurance easy.

Section One: Understanding Health Insurance ......................5

Section Two: Understanding Your Coverage ..........................8

Section Three: Getting Routine Care ....................................15

Section Four: Getting Urgent & Emergency Care ................24

Section Five: Taking Care of Yourself & Your Family ..............27

Section Six: Filling Your Prescriptions ....................................30

Section Seven: Important Notices ........................................40

Section Eight: Your Policy ......................................................55

GETTING HELP IN OTHER LANGUAGESSpanish (Español): Para obtener asistencia en Español, llame al 1-855-477-AZUL (2985).Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-355-BLUE (2583).Chinese (中文): 如果需要中文的帮助，1-800-355-BLUE (2583).Navajo (Dine): Dinek’ehgo shika at’ohwol ninisingo, kwiijigo holne’ 1-800-355-BLUE (2583).Additional language translation services and Text Telephone (TTY) service for the hearing impaired areavailable at no additional cost.

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We’re happy to have you as a member!Are you ready to get the most from your OMNIASM Health Plan?Follow these steps…

Carry your member ID cardIt’s the key to all your Horizon BCBSNJ benefits. Show it when you see your doctor, or go to a hospital or other health care professional. Note: Your card was mailed separately, as part of your QuickStartGuide.

Get to know your planStart with this handbook. It will help you understand what’s coveredand what’s not, as well as how to use your benefits. Not sure? Review your policy in Section 8: Your Policy or call Member Services.

Go onlineRegister for Member Online Services* at Register.HorizonBlue.com,then sign in at Members.HorizonBlue.com. You’ll find members-onlybenefit details, helpful health and wellness tools, and more. Have amobile device? We have an app for that, too.

Choose a doctorYour plan covers doctors and hospitals participating in OMNIA HealthPlans. Start by choosing an OMNIA Tier 1-designated doctor to takecare of you when you’re sick, and help you stay healthier all yearround.

See Section 3: Getting Routine Care to find out how to pre-select an OMNIA Tier 1-designated doctor.

Save moneyEnjoy member-exclusive discounts on fitness and healthy livingservices. Visit Blue365deals.com for details.

* This service is not available to all members and some group clients may not offer this service.

24/7 SupportMember Online ServicesMembers.HorizonBlue.com24/7 Nurse Line1-888-624-3096Pharmacy Member Services1-800-370-5088

Numbers to KnowMember Services1-800-355-BLUE (2583)Representatives are available onMonday, Tuesday, Wednesday and Friday between 8 a.m. and 6 p.m., Eastern Time (ET), and onThursday between 9 a.m. and 6 p.m., ET.

Self-service assistance is available 24 hours a day, sevendays a week.

Hearing impaired711

Plan FactsNameOMNIA

Participating Health CareProfessionalsRefer to Section 2: Understanding Your Coverage for details.

Out-of-Network ServicesExcept for emergency care,services provided by doctors,hospitals and other health careprofessionals that don’t participatein OMNIA plans are not covered.

Connect with us!@HorizonBCBSNJ

Detach this section and keep it for reference!

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MEMBER ONLINE SERVICES | MEMBERS.HORIZONBLUE.COM | 24 hours a day, seven days a week

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Use Member Online ServicesOur secure Member Online Services site is available to you 24 hours a day,seven days a week.

If you haven’t already, start by registering at Register.HorizonBlue.com.For access, visit Members.HorizonBlue.com and log in with your username and password.

Through Member Online Services, you can see detailed informationabout your plan, benefits and claims. You can also take advantage of healthand wellness tools, educational resources and more. You can even usehelpful tools from WebMD®* to securely store and track your personal healthinformation.

*WebMD is independent from and not affiliated with Horizon BCBSNJ.

Get the App**The Horizon Blue app gives you access toMember Online Services in the palm of yourhand. You can check plan benefits, find adoctor in our Online Doctor & HospitalFinder, and even display your HorizonBCBSNJ member ID card, all on the screenof your web-enabled mobile device.

**Available for iPhone® and AndroidTM devices.

Have a different phone or tablet?Try our mobile website at Mobile.HorizonBlue.com.

Claims

Choose a MemberJohn Doe

#12345678901234 Total Changes10/01/2015 $300.00Dr. Jane Doe Paid By PlanFinalized $100.00

Horizon ConnectSM

Retail CenterIf you’re in the area, stop byand meet the team of expertsat our retail center, HorizonConnect.

Where: 1680 Nixon Drive,Moorestown, New Jersey

When: Open Monday throughFriday, between 9 a.m. and 7p.m., Eastern Time (ET), andSaturday, between 9 a.m. and4 p.m., ET.

To make an appointment andregister for events, visitConnect.HorizonBlue.com.

At Horizon Connect, you can:

» Get answers to questionsyou may have about yourplan and benefits.

» Pick up informationalmaterials.

» Learn all about our healthand wellness tools.

» Attend health fairs andspecial events with localdoctors, nurses,pharmacists and otherhealth care professionals.

» Purchase health insuranceplans.


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ONE

UnderstandingHealth Insurance


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Health insurance may seem complicated andconfusing, but it doesn’t have to be. At HorizonBCBSNJ, we’re committed to helping you understandyour health insurance plan – how it works, how to useit and how you can get the most out of it.

What to expectIf you’ve never had health insurance before, you may not know what toexpect. In general, here’s how it works:

Copayment – A copayment may be due when you see a participatingdoctor or other health care professional (Step 1).Claims – The doctor or other health care professional’s office files a claim(Step 2), showing which services you received. We process each claimaccording to the terms of your plan.

If we owe a payment for covered services, we pay the participating doctoror other health care professional directly (Step 3).Explanation of Benefits (EOB) – After we process your participating doctoror other health care professional’s claims, we send you a Horizon BCBSNJExplanation of Benefits, or EOB (Step 4). This EOB statement shows what we paid the doctor or other health careprofessional for each service, and any amount you may still owe incoinsurance to the doctor or other health care professional (Step 5).You can also view EOB statements when you sign in to Member OnlineServices and click the claim number. You can also go paperless and signup to receive your EOBs electronically.

Medical Bills – After you see a participating health care professional, youmay not get a medical bill. But you should expect one if you owe acopayment or coinsurance, or if there are any charges for services that aren’tcovered under your plan. Services provided by nonparticipating doctors,hospitals and facilities are not covered under your plan for nonemergentservices, and you will be responsible for the total cost.Please note: Participating doctors, hospitals or other health careprofessionals are not permitted to “balance bill” you for any differencebetween their charges and Horizon BCBSNJ’s maximum allowed amount fora covered service. For example, say your doctor charges $200 for a service,and we allow $100 for that service. Because your doctor accepts adiscounted rate from Horizon BCBSNJ, the total your doctor gets – ourpayment, plus your coinsurance plus any copayment – is $100. Your doctorcan’t bill you for the $100 balance.

Of course, if you get any services that aren’t covered under your plan, you’llbe responsible for paying the doctor’s total charges.

Step 1

Step 2

Step 3

Step 4

Step 5

Copayment

Claim

EOB

Coinsurance

SECTION ONE: Understanding Health Insurance


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What do you pay?Each insurance plan is different. That’s why understanding your planand benefits is important. Knowing about your coverage will help youmake the best health care choices and avoid unexpected expenses.

You’ll find complete plan details in your policy (see Section 8: YourPolicy). But generally, this is how your health insurance works:

» You pay us a monthly premium for coverage.

» Each time you see a participating doctor, hospital or other health careprofessional, you may be asked to pay a fixed amount called acopayment.

» For some services, you may pay coinsurance – a set percentage basedon how much we agree to cover for a service (also known as our allowed amount). For example, if we allow a $100 charge for a coveredservice and your plan has 70 percent coinsurance, we would pay $70 andyou would be responsible for $30.

» Finally, your coverage may have an out-of-pocket maximum. If itdoes, this amount is the most you’ll have to pay “out of your pocket” incopayments, deductibles and coinsurance for certain covered healthcare services in a single year.

PRESCRIPTION MEDICINEWhen you fill a prescription, the amount that you pay depends on whereyou get your medicine, the type of medicine and the quantity (days supply).Your plan has a covered drug list (formulary). It has three levels, which are called tiers. The tier your medicine is on will tell you the amount you will pay.

» Generic drugs are Tier 1. Generic drugs are ensured by the U.S. Foodand Drug Administration (FDA) to be as safe and effective as their brandname equivalents. You could save between 30 and 80 percent over thecost of brand name drugs when you choose their generic equivalents.

» Preferred brand drugs are Tier 2. They are more expensive, but theymay be the right choice when there are no generic equivalents available.

» Non-Preferred drugs are Tier 3. They are usually the most expensive of all.

» Specialty drugs are covered on Tiers 1, 2 and 3. Specialty drugs requireprior authorization and are available only through our participatingspecialty pharmacy network. You cannot get specialty drugs from a retailpharmacy or through our home delivery pharmacy service, administeredby PrimeMail®.

» You can go to an in-network retail pharmacy to get your medicine. Youwill pay your retail copayment or coinsurance for each 30-day supply. Ifyou use the home delivery pharmacy PrimeMail, you will pay your mailorder copayment or coinsurance for up to a 90-day supply. If you use aparticipating specialty pharmacy, you will pay your retail copayment orcoinsurance for each 30-day supply.

Please note: Not all Horizon BCBSNJ members have Horizon BCBSNJ pharmacy benefits.Please read your Evidence of Coverage (EOC) to find out if this is part of your HorizonBCBSNJ benefits.

SECTION ONE: Understanding Health Insurance

PRIOR AUTHORIZATIONFOR MEDICINEFor certain medicines that haveside effects, can be misused,have quantity limits, or where ageneric alternative must beused before a brand iscovered, your doctor will haveto get prior authorizationbefore you can fill yourprescription. You’ll find theprior authorization drug list inSection 6: Filling YourPrescriptions.

See your plan’s updated druglist for tier information, anyspecial requirements,limitations and exclusions.Look up specific medicines bylogging in to Member OnlineServices atMembers.HorizonBlue.comand selecting PharmacyServices.


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TWO

UnderstandingYour Coverage


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What is Patient-Centered Care?Patient-centered care is an approach that helps you get the quality healthcare you deserve at a more affordable cost. Horizon BCBSNJ is transformingthe way health care is delivered in New Jersey by developing the state’slargest patient-centered network. Your OMNIA Health Plan offers you thebenefits of patient-centered care, along with access to all doctors, hospitalsand other health care professionals participating in the Horizon ManagedCare Network.

Patient-centered care is all about you. The doctors and practices thatparticipate in OMNIA Health Plans have committed themselves toincreasing patient satisfaction and achieving quality health outcomes.

When you select an OMNIA Tier 1-designated doctor as your doctor, youcan expect:

» A doctor who takes overall responsibility for your care.

» A team of health professionals, led and directed by your doctor, thatclosely monitors your health and responds to your specific needs.

» Wellness services and preventive care based on national guidelines,including wellness support and resources.

» Preventive services, screenings and immunizations that are fully coveredwhen you receive them from your doctor or another in-network doctor.

When you pre-select and see an OMNIA Tier 1-designated doctor, he or she can help you get the most appropriate care in the rightsetting. See Section Three: Getting Routine Care to learn how to pre-select an OMNIA Tier 1-designated doctor.

SECTION TWO Understanding Your Coverage

OMNIA TIER 1 ICONHorizon BCBSNJ identifiesOMNIA Tier 1-designateddoctors with a special icon in our Online Doctor & Hospital Finder atHorizonBlue.com/doctorfinder.

All other doctors in the HorizonManaged Care Network are Tier 2.


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Your planWhile your OMNIA Health Plan encourages you to get care from OMNIA Tier 1-designated doctors, hospitals and other health careprofessionals, your plan covers all medically necessary care and servicesprovided or arranged by doctors and other health care professionalsparticipating in the Horizon Managed Care Network, and all hospitals in theHorizon Hospital Network.

Under your plan, you’re not required to choose a Primary Care Physician(PCP). But when you pre-select and see an OMNIA Tier 1-designateddoctor, he or she can help you get the most appropriate care in the right setting.Check your member ID card or refer to Section Eight: Your Policy forspecific out-of-pocket costs, benefit information and exclusions.

Questions? Sign in to Members.HorizonBlue.com to review your coverageinformation, or call Member Services at the number on your ID card.

Finding participating health care professionalsNeed to find a participating doctor, hospital or other health careprofessional? Check the Online Doctor & Hospital Finder atHorizonBlue.com/doctorfinder.To find OMNIA Tier 1-designated doctors:» Select the type of health care professional you’re looking for from the

What are you looking for? dropdown list and your OMNIA Health Planfrom the Choose a plan to start dropdown list. You can also refine yoursearch by entering a ZIP code or other criteria.

» You can identify OMNIA Tier 1 doctors and specialists by looking for this icon.

All other doctors will be listed as Tier 2.

To find OMNIA Tier 1 specialists:

» Select a specialty in the Specialty dropdown list, or enter a specialty in the Search box, and select your OMNIA Health Plan from the Choose aplan to start dropdown list.

To find OMNIA Tier 1 Hospitals:

» Select Hospitals in the What are you looking for? dropdown list, and yourOMNIA Health Plan from the Choose a plan to start dropdown list. Lookfor participating hospitals with OMNIA Tier 1 in the search results.

» Remember, you’ll pay less if you select and see OMNIA Tier 1 doctors,specialists and hospitals.

Remember – services provided by doctors, hospitals and other healthcare professionals that do not participate in OMNIA Health Plans are notcovered. You’ll be responsible for the total cost of any of the out-of-network services you receive (except in the case of an emergency).

SECTION TWO: Understanding Your Coverage

IMPORTANT TERMSCopayment –The amount youmust pay for each medical visitto a participating doctor,hospital or other health careprofessional. Your copaymentamounts are listed on yourHorizon BCBSNJ member ID card.

Coinsurance –The percentageof a covered charge that theinsurer pays. For example, ifyour plan has 80 percentcoinsurance, you areresponsible for 20 percent ofcovered charges. Coinsurancedoes not include deductibles,copayments and charges for non-covered services.

Deductible –The amount youmust pay each year beforebenefits are paid by us.

OMNIA Tier 1 – When youreceive services from anOMNIA Tier 1 doctor, hospitalor other health careprofessional, you can savemoney.

Remember, OMNIA Tier 1doctors, hospitals and otherhealth care professionals areidentified by the following iconin our Online Doctor & HospitalFinder:

Tier 2 – Under your OMNIAHealth Plan, you are stillcovered at an in-networkbenefit level when you receiveservices from a Tier 2 doctor,hospital or other health careprofessional.

However, you can lower your out-of-pocket costs byreceiving services from OMNIATier 1 doctors, hospitals andother health care professionals.


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Benefit highlightsHEALTH CARE SERVICES YOU PAY

OMNIA Tier 1 Primary Care Physician (PCP) office visits Deductible then copayment

Tier 2 PCP office visits Deductible then copayment or coinsurance

OMNIA Tier 1 specialist office visits and consultation Deductible then copayment

Tier 2 specialist office visits and consultation Deductible then copayment or coinsurance

OMNIA Tier 1 other practitioner office visits Deductible then copayment

Tier 2 other practitioner office visits Deductible then copayment or coinsurance

Preventive care, screenings, immunizations No copayment or deductible

TESTS & IMAGING YOU PAY

OMNIA Tier 1 diagnostic tests (X-rays, blood work) Deductible then copayment

Tier 2 diagnostic tests (X-rays, blood work) Deductible then coinsurance

OMNIA Tier 1 imaging (CT/PET scan, MRI) Deductible then coinsurance

Tier 2 imaging (CT/PET scan, MRI) Deductible then coinsurance

OUTPATIENT SURGERY YOU PAY

OMNIA Tier 1 hospital Deductible then coinsurance

Tier 2 hospital Deductible then coinsurance

OMNIA Tier 1 physician/surgeon Deductible then coinsurance

Tier 2 physician/surgeon Deductible then coinsurance

OMNIA Tier 1 ambulatory surgical center – hospital Deductible then coinsurance

Tier 2 ambulatory surgical center – hospital Deductible then coinsurance

OMNIA Tier 1 ambulatory surgical center – physician Deductible then coinsurance

Tier 2 ambulatory surgical center – physician Deductible then coinsurance

URGENT & EMERGENCY MEDICAL SERVICES YOU PAY

OMNIA Tier 1 Emergency Room services – hospital Deductible and coinsurance after copayment

Tier 2 Emergency Room services – hospital Deductible and coinsurance after copayment

OMNIA Tier 1 Emergency Room services – professional Deductible then coinsurance

Tier 2 Emergency Room services – professional Deductible then coinsurance

Emergency medical transportation (e.g., ambulance) No charge after deductible

OMNIA Tier 1 urgent care center Deductible then copayment

Tier 2 urgent care center Deductible, then copayment or coinsurance

HOSPITAL SERVICES YOU PAY

OMNIA Tier 1 hospital and physician/surgeon Deductible then coinsurance

Tier 2 hospital and physician/surgeon Deductible then coinsurance

(Continues)


Benefit highlightsBEHAVIORAL HEALTH & SUBSTANCE ABUSE SERVICES YOU PAY

OMNIA Tier 1 specialist office visits and consultation Deductible then copayment

Tier 2 specialist office visits and consultation Deductible, then copayment or coinsurance

OMNIA Tier 1 outpatient/inpatient services Deductible, then copayment or coinsurance

Tier 2 outpatient/inpatient services Deductible then coinsurance

MATERNITY SERVICES YOU PAY

Prenatal and postnatal care No copayment or deductible

OMNIA Tier 1 delivery and all inpatient services Deductible, then copayment or coinsurance

Tier 2 delivery and all inpatient services Deductible then coinsurance

RECOVERY/SPECIAL HEALTH SERVICES YOU PAY

In-home health care Deductible then copayment

OMNIA Tier 1 rehabilitation services Deductible then coinsurance

Tier 2 rehabilitation services Deductible then coinsurance

OMNIA Tier 1 skilled nursing care – inpatient Deductible, then copayment or coinsurance

Tier 2 skilled nursing care – inpatient Deductible, then copayment or coinsurance

OMNIA Tier 1 durable medical equipment (DME) – outpatient Deductible then coinsurance

Tier 2 durable medical equipment (DME) – outpatient Deductible then coinsurance

Hospice service (less than six month life expectancy) – inpatient Deductible, then copayment or coinsurance

PHARMACY SERVICES YOU PAY

Generic drugs Deductible then coinsurance

Preferred brand drugs Deductible then coinsurance

Non-preferred brand drugs and specialty drugs Deductible then coinsurance

OTHER COVERED SERVICES YOU PAY

OMNIA Tier 1 chiropractic care – 30 visits per year maximum Deductible then copayment

Tier 2 chiropractic care – 30 visits per year maximum Deductible then copayment or coinsurance


12 MEMBER ONLINE SERVICES | MEMBERS.HORIZONBLUE.COM | 24 hours a day, seven days a week

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LIMITATIONS AND EXCLUSIONSPrior authorization: Under your plan, Horizon BCBSNJ must authorizeall non-emergency hospitalizations and some specialty care services(except for routine Ob/Gyn) before you receive these types of services.

Non-covered services: Your OMNIA Health Plan does not pay for servicesor supplies that are not covered under your policy.

Please refer to Section 8: Your Policy for more details, or call MemberServices.

What if you get a medical bill?Whenever you see a participating doctor or other health care professional,you’ll be asked for a copayment, if one applies. For all other charges, thedoctor or other health care professional should bill us directly by filing a claim.

After we process your claim, you will receive a Horizon BCBSNJ Explanationof Benefits (EOB) that explains what we paid and what you may owe. Youmay also receive a bill from your doctor or other health care professional foryour share of costs (coinsurance plus any covered amount that goes towardmeeting your deductible, if applicable).

Always keep a copy of your medical bills for your records.

Who’s covered?Your Horizon BCBSNJ health plan offers coverage that fits your needs. Asyour family situation changes, you can easily apply to enroll or removemembers.

Your coverage choices may include:

*If you have employer-sponsored coverage, please contact your benefits administrator todetermine if this coverage option was selected for your plan.

You and your spouse, domestic* partner or civil union partner

You and one or more children

You You and your spouse,domestic partner or

civil union partner, andone or more children

+ + +


KNOW WHAT YOU OWEBefore you pay any participating health care professional’s medical bill,check it against your HorizonBCBSNJ Explanation of Benefits (EOB) to see whatwe paid and how much youmay owe. Remember, you cansee current and past claimsany time by signing in toMember Online Services andclicking on the claim number.


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COVERING YOUR SPOUSE, DOMESTIC PARTNER OR CIVIL UNION PARTNERWant to add a spouse, civil union partner, domestic partner or common lawspouse to your plan? Please refer to Section Eight: Your Policy for moredetails, or call Member Services.

Note: For coverage purchased through the Health Insurance Marketplace,the eligibility date for an added spouse, partner or dependent(s) is subjectto the Marketplace’s determination.

COVERING CHILDRENYou may also add eligible children to your plan. Here are the eligibilityrequirements.

Child: An eligible child must be under age 26 years. He or she may be yourown child, a legally adopted child, a stepchild, your domestic partner’s child(if your employer extends coverage to domestic partners), your civil unionpartner’s child, a foster child or a child of whom you have court-appointedguardianship.

Handicapped or Developmentally Disabled Child: A child who hasreached age 26 years may be eligible to continue coverage if he or she hasa mental/physical incapacity. Among other documentation, we’ll need proofof the child’s incapacity, along with proof that he or she depends on you forsupport and maintenance.

Children who have reached age 26 years: When your child reaches age 26 years, he or she may be able to stay under your employer’s group healthplan coverage by electing continuation coverage through one of these:

» COBRA

» New Jersey’s Group Continuation (NJGC) law

» New Jersey’s Dependent Under 31 law (DU31)

If you get coverage under your employer’s group health benefits plan afteryour child reaches the limiting age but before his or her 31st birthday, he orshe may be eligible to enroll under your plan by making a DU31 election. Ifyour child already has coverage under his or her own employer plan or anindividual policy, then he or she would have to give up the existing policy tobe covered under your employer’s group health plan.

For more information about child/dependent coverage and to checkeligibility, please refer to Section Eight: Your Policy.


FORMS AT YOUR FINGERTIPSNeed a claim form? Downloadone at HorizonBlue.com/members/forms or callMember Services. Mail yourcompleted claim form and billto the address shown on the form.


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THREE

GettingRoutine Care


If you haven’t already, selecting a doctor who willknow your medical situation and coordinate your careis one of the first things you should do.

With your OMNIA Health Plan, you’re not required to choose a PrimaryCare Physician (PCP). But when you pre-select and see an OMNIA Tier 1-designated doctor, he or she can help you get the most appropriate care in the right setting.

Choosing your DoctorYou can change your doctor at any time, either online or by phone.

To select a new doctor:

OnlineSign in to Member Online Services at Members.HorizonBlue.com.

Click the Tools & Resources tab. Select Self Service and click Change Provider, then follow the instructions.

When you choose an OMNIA Tier 1-designated doctor (identified with the icon), you’ll maximize your benefits by lowering your out-of-pocket costs.

By phoneCall Member Services at 1-800-355-BLUE (2583) at any time tochange your doctor through our interactive voice response system. Or, call the same number during regular hours to speak with a MemberServices Representative. To make the most of your benefits and payless out of pocket, remember to ask for an OMNIA Tier 1-designateddoctor.Once you make a change using any of these methods, we will send you a letter confirming your new doctor.

Be sure to have your medical records transferred to your new doctor.

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SECTION THREE: Getting Routine Care

DOCTOR RESPONSIBILITIESThe doctor you choose will beyour main resource for healthcare services. He or she will:

» Handle most of yourmedical care in his or herown office

» Perform most of yourannual wellness andpreventive health exams

» Take care of youremergency care needswhen possible

» Get prior authorizationsfrom us for medicallynecessary services

» Help coordinate the careyou get from specialistsand other participatinghealth care professionals

» Be available on call (orappoint a covering doctorto be available) 24 hours aday, seven days a week

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Making an appointmentACCESS STANDARDSTo make sure you can get the medical care you need when you need it, wedeveloped these Physician Access Standards for participating doctors inselected specialties*. These health care professionals follow our PhysicianAccess Standards** when scheduling appointments with you.

» EMERGENCY CARE – Immediate care Includes “a medical condition of such severity that a prudent laypersonwould call for immediate medical attention and care.” (To learn more,please see Section Four: Getting Urgent & Emergency Care.)

» URGENT CARE – Care within 24 hours Includes medically necessary care for an unexpected illness or injury.

» ROUTINE CARE – Care within two weeks*** Any condition or illness that does not require urgent attention or is notlife-threatening, as well as routine gynecological care.

» ROUTINE PHYSICAL EXAM – Care as soon as possible, but not toexceed four months from the date of your call Includes an annual health assessment, as well as routine gynecologicalexams, for new and established patients.

OFFICE WAITING TIMEHorizon BCBSNJ’s participating doctors are expected to keep office waitingroom time to 30 minutes or less from the time of your scheduledappointment, or when you arrive at the office, whichever is later. If your waitis longer than 30 minutes, you should be given the choice to reschedule orcontinue waiting.

NIGHTS AND WEEKENDSIf you need urgent care after your doctor’s office hours or on weekends,your doctor should be reachable 24 hours a day, seven days a week.

When your doctor is not available, he or she should refer you to a coveringdoctor who can help you.

If you believe your condition requires emergency care, follow themedical emergency procedures in Section Four: Getting Urgent &Emergency Care.

* Applies to doctors who are directly under contract with Horizon BCBSNJ.

** Standards apply to first available appointment, not first convenient appointment.

*** Specialists must offer an appointment for routine care within three weeks.

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HAVE A MEDICAL QUESTION? CALL THENURSE LINEWhen you have a non-emergency medicalquestion, our 24/7 Nurse Line*is ready to help at no cost toyou.

The Horizon BCBSNJ 24/7Nurse Line is available 24hours a day, seven days aweek, to help you make wisehealth care decisions. Ourteam of registered nurses canhelp you understand a medicalproblem, review treatmentoptions, answer questionsabout medications, assist withquestions to ask your doctorand more.

Call the 24/7 Nurse Line anytime at 1-888-624-3096. Allcalls are confidential.

24/7 NURSE LINE ONLINEOur nurses can also assist youonline. Sign in to MemberOnline Services atMembers.HorizonBlue.comto chat live with a registerednurse who can answer yourquestions and provideinformation on healthsymptoms, wellness, drugs, up-to-date health news and more.

* For informational purposes only. This service is not available to allmembers and some group clientsmay not offer this service. Nursescannot diagnose problems orrecommend specific treatment. They are not a substitute for yourdoctor’s care. The 24/7 Nurse Lineservices are not an insuranceprogram and may be discontinued at any time. In the event of anemergency, please go to the nearesthospital or doctor or call 911 or yourlocal emergency services number.


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A faster, easier way to see a doctorHorizon BCBSNJ makes it easier for you to stay in control of your health byoffering Horizon CareOnlineSM. Horizon CareOnline*, connects eligiblemembers with doctors by mobile, web or phone – whenever and whereverthe need arises. We are working with Amwell**, a leader in telehealth, tobring you care that is:

» Dependable: 24/7/365 access

» Flexible: Access to licensed, U.S. board-certified doctors

» Convenient: No appointment needed, no waiting

» Confidential: Private and secure; compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

You can be treated for symptoms and conditions such as:

» allergies » fever » stomach pain

» cold » flu » and much more.

» earaches » pinkeye

WHO ARE THE DOCTORS?Clinical services for Horizon CareOnline are provided by doctors who:

» Are U.S. board certified, licensed and credentialed.

» Average 15 years’ experience in primary and urgent care.

» Are rated by other patients.

It’s free to sign up – enroll today to get started. Use the appropriate codebelow to download*** the Amwell app to your web-enabled mobile device:

Or call 1-855-818-DOCS (3627).

Once you are enrolled, you can visit with a doctor on Horizon CareOnlinewhen:

» Your doctor’s office is closed.

» You feel too sick to drive.

» You are traveling and need medical care.

This valuable service is offered as a convenience and does not replace yourrelationship with your personal doctor.*This service is not available to all members and some group clients may not offer this service.** Amwell is an independent company that supports Horizon Blue Cross Blue Shield of New Jersey in theadministration of telehealth services. Telehealth is available in most states, with the exception of AK, AL, AR,LA and TX, where state regulations prohibit providers from practicing online. The following states allowonline visits, but don't allow doctors to prescribe medications: CO, IN, NH and NJ. Even if your state doesnot allow telehealth at this time, you can still enroll and use Horizon CareOnline when traveling outside that state.*** There is no charge to download the Amwell App, but rates from your wireless provider may apply.

Scan this with youriPhoneTM device orsearch the App Storefor Amwell.

Scan this with yourAndroidTM device orsearch Google Playfor Amwell.

HAVE QUESTIONS?Go to HorizonBlue.com/FAQsto read answers to frequentlyasked questions about benefits,claims, enrollment and more.

If you don't see an answer to your question, you can send usyour question through oursecure online Message Center.Simply sign in to MemberOnline Services atMembers.HorizonBlue.comand click My Message Center.Once signed in to MemberOnline Services, you can alsocheck the status of a claim,review your benefits, print an ID card and more.


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How to get specialist careA specialist is a doctor who “specializes” in taking care of a particular bodilysystem or disease. Cardiologists (heart care) and oncologists (cancer care)are two common types, but there are many more kinds of specialists.

With your OMNIA Health Plan, no referral is needed to see a specialist.

PRIOR AUTHORIZATION“Prior authorization” means that Horizon BCBSNJ must approve certainspecialty services before you receive them. Without proper authorization,you might receive services that are not covered by your plan, leaving youresponsible for the total cost.

Please refer to Section Eight: Your Policy for more details.

GETTING BEHAVIORAL HEALTH AND SUBSTANCE ABUSE CAREPlease see page 23 for more information.

How to get a lab testLaboratory Corporation of America® (LabCorp) and AtlantiCare ClinicalLaboratories* are the exclusive in-network clinical laboratory providers formembers enrolled in OMNIA Health Plans. When you need clinicallaboratory tests, your doctor may collect specimens at his or her office orsend you to a LabCorp or AtlantiCare patient service center.

If your doctor sends you to a lab, he or she will give you a LabCorpRequisition Form. This form may also be used at AtlantiCare ClinicalLaboratories. Simply present the form and your Horizon BCBSNJ memberID card when you check in.

Note: If you use a testing facility other than LabCorp or AtlantiCare ClinicalLaboratories, your tests will not be covered and you will have to pay theirtotal cost. If you get a bill from LabCorp or AtlantiCare Clinical Laboratories,please call Member Services.

* AtlantiCare Clinical Laboratories works in collaboration with LabCorp.

LABCORP LOCATIONS:You can find the LabCorp PatientService Center nearest you atlabcorp.com/psc

ATLANTICARE CLINICALLABORATORIES LOCATIONS:» Atlantic City at The HealthPlex,

1401 Atlantic Avenue

» Egg Harbor Township at 2500English Creek Road, Building900, Suite 910

» Hammonton at 219 North WhiteHorse Pike

» Marmora at 210 South ShoreRoad, Suite 200

» Northfield at 1601 Tilton Road

» Ocean City at 201 West Avenue

» Pomona at Stockton MedicalCenter, 76 West Jimmie LeedsRoad, Suite 202

» Ventnor at 6725 VentnorAvenue

To find the AtlantiCare ClinicalLaboratory nearest you, visitatlanticare.org/index.php/locations-home.

HORIZON BCBSNJHEALTH TIPDon’t miss out on yourpreventive care benefits. Be sure to make appointmentsfor physical examinations and related services well inadvance. (See Section Six:Taking Care of Yourself &Your Family for more onpreventive care benefits and guidelines.)

SECTIONTHREE: Getting Routine Care


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How to get an X-ray or imaging scan (radiology)Horizon BCBSNJ works with eviCore healthcare* for nonemergency,outpatient radiology and diagnostic imaging services. eviCore healthcarewill help schedule and manage your office and outpatient radiology anddiagnostic imaging, determine whether a service is medically necessary andconfirm a location for the service.

*eviCore healthcare (formerly CareCore) is independent from and not affiliated with HorizonBCBSNJ.

SCHEDULING YOUR TESTSIf your doctor decides that you need general radiology (e.g., X-ray,mammogram, ultrasound, etc.), he or she will ask you to call eviCorehealthcare’s easy-to-use Scheduling Line. You won’t need a doctor referralfor radiology services. The eviCore healthcare scheduling staff willcoordinate with the participating imaging center of your choice to scheduleyour exam and provide you with a confirmation number.

To make an appointment, call the eviCore healthcare Scheduling Line at1-866-969-1234, Monday through Friday, between 7 a.m. and 7 p.m.,Eastern Time.

ADVANCED IMAGING SERVICES (AIS) AND CARDIOLOGY IMAGINGPROCEDURESYour doctor must call eviCore healthcare before you can receive any ofthese advanced procedures:

» CT/CTA scans

» Diagnostic left-heart catheterization

» Echo stress tests

» Echocardiograms

» MRIs/MRAs

» Nuclear medicine studies (including nuclear cardiology)

» PET scans

For more information about X-rays and imaging, call Member Services orrefer to Section Eight: Your Policy for coverage details.

Note: You can make an appointment for radiology services at a hospitaloutpatient department through eviCore healthcare’s Scheduling Line.eviCore healthcare will issue a tracking number that can be used as areferral.


HORIZON BCBSNJ COST-SAVING TIPSDon’t forget out-of-network(or nonparticipating) doctors,hospitals and services are notcovered under your plan. Ifyou use an out-of-networkdoctor, hospital or otherhealth care professional, youwill be responsible for thetotal cost.

If your doctor prescribes aPreferred or non-Preferredmedication, ask if there’s ageneric medication that willwork as well. Genericmedications could save youbetween 30 and 80 percentover the cost of brand name medications.


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What if you need to be hospitalized?Your OMNIA Health Plan offers coverage at participating New Jerseyhospitals.

To find a participating hospital, go to the Online Doctor & Hospital Finder atHorizonBlue.com/doctorfinder, select Hospitals in the What are youlooking for? dropdown, and select your OMNIA Health Plan in the Choose aplan to start dropdown. Look for participating hospitals with the OMNIATier 1 designation in the search results.

Remember – except for emergency care, services provided by hospitalsthat do not participate in OMNIA Health Plans are not covered. You’ll beresponsible for the total cost of any services you get fromnonparticipating hospitals.For details about participating coverage and cost sharing under your plan,see your Schedule of Insurance in Section Eight: Your Policy.

How to get help with a serious condition If you’re diagnosed with a serious medical condition or told that you needmajor surgery, you may be eligible for the Horizon BCBSNJ CaseManagement Program.

Think of your Case Manager as your link to Horizon BCBSNJ, helping younavigate your coverage to get the right care at what could be a difficult,stressful time. Each Case Manager is a registered nurse who is trained tohelp you examine your options for available specialists, hospitals andmedical care while maximizing your health plan benefits.

If you face a challenging medical condition, let our Case Managers help – atno additional cost to you. You can reach a Case Manager at 1-888-621-5894, option 2, Monday through Friday, between 8 a.m. and 5 p.m., Eastern Time.

HOSPITAL STAYS ANDPRIOR AUTHORIZATIONFor your inpatient oroutpatient* hospitalization tobe covered, your doctor mustcontact us for priorauthorization, and you mustreceive care from aparticipating facility.

If you receive care at anonparticipating hospital whenit’s not an emergency, you’ll beresponsible for the total cost.

*Not all outpatient hospitalservices require prior authorization.For more information, please referto Section Eight: Your Policy.

CASE MANAGER DUTIESA Horizon BCBSNJ CaseManager can educate youabout your condition, help youget quality medical care, secureappropriate authorizations andconnect you to valuableresources. If your medicalcondition requireshospitalization, your CaseManager will see to it that yourfollow-up needs are met whenyou leave the hospital.

Your Case Manager can alsohelp you improve your health,work with you to preventcomplications, help you livewithin the boundaries of a newhealth status, and assist youand your family with adjustingto a new lifestyle that optimizesyour quality of life.



What if you become pregnant?If you become pregnant, your Horizon BCBSNJ healthplan will be with you and your obstetrician every stepof the way, with comprehensive prenatal and maternity coverage.

PARTNERING WITH YOUR OB/GYNHorizon BCBSNJ supports the American College of Obstetricians andGynecologists’ recommendation for 12 obstetrical visits during a normalpregnancy. Your obstetrician will decide how many visits are right for you.

If your obstetrician decides you need more specialized care, you may bereferred to a Case Management Nurse. This registered nurse will helpensure that you and your unborn baby have the most appropriate care. Tolearn more about our Case Management services, please call 1-888-621-5894, option 2.

MATERNITY HOSPITAL STAYSNew mothers are certified for a hospital stay of 48 hours following a vaginaldelivery or 96 hours following a caesarean section. Your hospital stay maybe extended if your doctor thinks it’s medically necessary. To be covered,your doctor will need to contact us for approval of the additional days.

Your doctor may decide that you’re ready to leave the hospital early –within one day after a vaginal delivery or within two days after a caesareansection. If you do leave early, you become eligible for a home care visit tosupport your move from hospital to home. To be covered, your Ob/Gynmust schedule the visits to occur within seven (nurse/lactation consultant) to14 (home health aide) days after you’ve left the hospital.

MATERNITY HEALTH COACHYou may also have access to a Maternity Health Coach through the 24/7 Nurse Line. Registered nurses will provide one-on-one counseling and educational support to help address your:

» Pregnancy concerns.

» Health issues that might affect your pregnancy or delivery.

» Questions that you may have before and after your pregnancy.

Your Maternity Health Coach will help you throughout your pregnancy soyou can feel comfortable about the healthy choices you make for you andyour baby.

Eligible members can reach a Maternity Health Coach at 1-888-624-3096, Monday through Friday, between 8 a.m. and 8 p.m., Eastern Time.

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PRECIOUS ADDITIONS®

As an expectant mother, youmay have questions andconcerns about your pregnancyand delivery. That’s why wedeveloped the PRECIOUSADDITIONS program.

PRECIOUS ADDITIONS* is aneducational program whereeligible members can receiveinformation about pregnancy,childbirth, the postpartumperiod and their child’s firstyear of life. The program willhelp provide guidance formaking healthy and safechoices during this specialtime.

Eligible members can enroll inPRECIOUS ADDITIONS by visitingHorizonBlue.com/PreciousAdditions or callingMember Services.

* This service is not available to allmembers and some group clientsmay not offer this service. Someproducts and services included in thePRECIOUS ADDITIONS program materialsare provided by independentcompanies that do not provideHorizon BCBSNJ products orservices. These companies are solelyresponsible for their products and services.


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What if you need behavioral health orsubstance abuse care?Your Horizon BCBSNJ health plan includes behavioralhealth and substance abuse coverage. Horizon Behavioral HealthSM provides assistance with a widerange of emotional and relationship issues, depression, alcoholism, addictions and more, throughan extensive network of health care professionals andfacilities.

AVAILABLE SERVICESHorizon Behavioral Health professionals offer a full range of counselingservices, including:

» Individual and group psychotherapy

» Family counseling and crisis intervention

» Addiction recovery programs

» Autism care management program

GETTING BEHAVIORAL HEALTH AND SUBSTANCE ABUSE CAREFor routine behavioral health or alcohol/substance abuse care,* please callHorizon Behavioral Health at 1-800-626-2212. Behavioral health andsubstance abuse care is available 24 hours a day, seven days a week. Allcalls are confidential.

Prior authorization is required for all behavioral health and substance abuseinpatient care. Routine outpatient hospital care and office visits don’trequire prior authorization, but do require coordination of care.

* Due to the confidential nature of these services, you may need to authorize the disclosure oftreatment information during or after your course of treatment. Authorization might also beneeded to allow any individual (including family members) to get a member’s behavioralhealth/substance abuse treatment information.



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FOUR

Getting Urgent &Emergency Care


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Immediate careYou may have an urgent medical condition – one thatcan’t wait for a normal appointment but is not a truemedical emergency, either.

For urgent care, contact your doctor or his or her covering doctor first. He or she can help you determine the type of care that is best for you.

YOUR URGENT CARE OPTIONS:

Your DoctorCall first, especially if you’re not sure it’s really an emergency. Yourdoctor may tell you how to treat the condition yourself, send youto the nearest urgent care center or make an appointment to seeyou as soon as possible.

Horizon CareOnline*Horizon CareOnline connects you with doctors by mobile, web orphone – whenever and wherever the need arises. Once you areenrolled, you can visit with a doctor on Horizon CareOnline whenyour doctor’s office is closed, you feel too sick to drive or you aretraveling and need medical care.

24/7 Nurse Line** (1-888-624-3096)The 24/7 Nurse Line is always available to answer your medicalquestions. When you call, a registered nurse will help you decidewhether a condition is urgent or a true medical emergency.

Urgent Care CenterAn Urgent Care Center is a good alternative when you need careright away and you’re not near your doctor’s office. Plus, you’llprobably have a much shorter wait for non-critical care than at an Emergency Room (ER), and your out-of-pocket costs may belower too. Please note: Routine office visits, annual physicals,sports physicals, routine obstetric services, occupational medicineand physical therapy are not covered at Urgent Care Centers. Youcan find an Urgent Care Center by using the Online Doctor &Hospital Finder at HorizonBlue.com/doctorfinder.

Emergency RoomFor treatment of a severe illness or injury, go to the nearest ERright away, or call 911 or your local emergency number.

* This service is not available to all members and some group clients may notoffer this service.

**24/7 Nurse Line is not available to all members and some group clients may notoffer this service. Please check with your benefits administrator. Nurses cannotdiagnose problems or recommend specific treatment. They are not a substitutefor your doctor’s care. In the event of an emergency or if you believe you have alife-threatening medical situation, please go to the nearest hospital or call 911 or your local emergency number.

IS IT REALLY AN EMERGENCY?Knowing the differencebetween urgent care and amedical emergency can saveyou time and money.

Urgent care situationsinclude:» Sprains

» Earache

» Moderate fever

» Sore throat

This is not a complete list ofurgent care situations. Forthese and other commonmedical conditions, call yourdoctor or visit an urgent carecenter.

Medical emergenciesinclude:» Severe burns

» Heart attacks and strokes

» Poisoning

» Obvious bone fractures

» Wounds requiring sutures

» Loss of consciousness

This is not a complete list ofemergency situations. For these and other serious or life-threatening conditions,seek immediate treatment bygoing to an ER, or call 911 oryour local emergencyresponse number.

SECTION FOUR: Getting Urgent and Emergency Care


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Emergency careIn general, an emergency is defined as “a medicalcondition of such severity that a prudent laypersonwith average knowledge of health and medicinewould call for immediate medical attention.”

If you reasonably believe that a condition is a medical emergency:

Go directly to the nearest ER or call 911 or your local emergencyresponse number.Call your doctor. In some situations, you may be able to call yourdoctor before you go to the ER. If you can’t, call as soon as reasonablypossible, or ask a family member or friend to call. It is important thatyour doctor be kept aware of your condition. Without this information,he or she cannot coordinate your care.

You do not need to call Member Services to notify us of a medicalemergency.

MEDICAL EMERGENCY SCREENING EXAMSometimes, you may not be sure if your condition requires emergency care.Your plan covers a medical emergency screening exam, which is anevaluation performed in a hospital ER by qualified health care personnel, to determine if a medical emergency exists. We’ll cover the cost of theemergency screening exam. If the exam determines that an emergencydoes not exist, please follow up with your doctor.

Note: If you continue to receive care at the ER after you have been advisedthat your condition is not a medical emergency, you will have to pay thetotal cost for any non-emergency-related services you receive.

EMERGENCY ROOM COPAYMENTSEven if your doctor refers you to the ER, you’ll have an ER copayment andmay also be responsible for a deductible and coinsurance. Each time you are treated at an ER or are given a medical emergency screening exam,you will be responsible for a copayment as well as any coinsurance yourplan requires. But if you’re admitted to the hospital as an inpatient within 24 hours, we’ll waive the ER copayment.

For details about cost sharing under your plan, please refer to Section Eight: Your Policy.

FOLLOW-UP CARE AFTER AN EMERGENCY ROOM VISITContact your doctor. He or she should coordinate all medical emergencyfollow-up care.

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1

SECTION FOUR: Getting Urgent and Emergency Care


27

FIVE

Taking Care of Yourself & Your Family


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Getting preventive careOne of your most important Horizon BCBSNJ benefitsis the one you use when you’re not sick – our wellness and preventive care coverage. Taking advantage of your covered preventive care services –checkups and counseling – may improve your healthand help you avoid illness. Best of all, routine participating preventive care is available at no additional cost to you.

We encourage you to visit your doctor for annual physical examinations.Early detection of any illness offers your best chance for recovery.

Well and preventive care coverage includes:

» Annual physical exams

» Well child care (including immunizations and lead screenings)

» Cancer screenings (including colorectal, breast, cervical and prostate)

» Tests (laboratory work, X-rays)

» Annual dilated retinal exams for members who have been diagnosedwith diabetes*

* Some group contracts may not cover this annual exam. Please refer to your EOC for specificbenefit information. No referral is necessary for this exam if you have been diagnosed with diabetes.

Preventive health care guidelinesGetting the right wellness and preventive care starts with a conversationbetween you and your doctor. Here’s where to start:

For adults» Schedule annual physical exams

» Ask your doctor about any additional screenings, examinations andimmunizations that may be appropriate for you

For children» Consult your child’s doctor about specific recommendations for

examinations, screenings, tests and vaccines

For a complete list of the preventive health guidelines visitHorizonBlue.com/Members and mouse over Health and Wellnessand click Wellness Messages.

Please refer to Section Eight: Your Policy for more details, or call Member Services.

SECTION FIVE: Taking Care of Yourself & Your Family

CHILDHOOD IMMUNIZATIONSAre your children up to date onimmunizations?

The Centers for DiseaseControl and Prevention (CDC)has recommended catch-upschedules for children andadolescents who start late orfall behind on theirimmunizations. Usually, there’sno need to restart a vaccineseries regardless of the timebetween doses. Ask your child’spediatrician for guidance.

For additional reasons tovaccinate children andadolescents in high-risk groups,as well as the recommendedcatch-up schedule, visit theCDC website at cdc.gov. Youcan also find immunizationcharts in English and Spanish atthe CDC National ImmunizationProgram site:cdc.gov/vaccines.

NOTES:» Horizon BCBSNJ preventive

care guidelines arecontinually reviewed andmay change.

» Always discuss yourparticular preventive careneeds with your doctor. He or she will help youdecide which preventivecare services are appropriatefor you.

» Some of the services andsupplies described in ourpreventive care guidelinesmay not be covered benefitsunder your health plan.Please refer to Section 8:Your Policy to see whichservices and supplies arecovered benefits for you.


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SECTION FIVE: Taking Care of Yourself & Your Family

Chronic condition health and wellness programs Our Chronic Care Program helps members who have chronic conditionstake better care of their health, understand their care choices andimprove their well-being. This program is available at no added cost toeligible members who have:

» Asthma

» Chronic Kidney Disease (CKD)/End-Stage Renal Disease (ESRD)

» Coronary Artery Disease (CAD)

» Chronic Obstructive Pulmonary Disease (COPD)

» Diabetes

» Heart Failure

To learn more about Horizon BCBSNJ Chronic Care Programs or toenroll, visit HorizonBlue.com/chronic-care or call 1-888-334-9006,Monday through Friday, between 8 a.m. and 7 p.m., Eastern Time. If youhave hearing or speech difficulties, please call the TTY/TTD line at 711.

Blue365® healthy discountsSaving money never felt so healthy! Presenting the next generationBlue365* – a fresh take on our valued member discount program.Blue365 has a brand-new look, a range of new features and even greaterdiscounts from top national and local retailers on fitness gear, gymmemberships, family activities, healthy eating options, and much more.

Visit Blue365deals.com/HorizonBCBS to find deals on:

» Fitness

» Healthy Eating

» Living

» Personal care

» Wellness

* Blue365 offers access to savings on items and services that members may purchasedirectly from independent vendors. Please note that the Blue Cross and Blue ShieldAssociation (BCBSA) may receive payments from Blue365 vendors. Also, neither Horizon BCBSNJ nor the BCBSA recommend, warrant or guarantee any specific Blue365 vendor or discounted item or service.


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SIX

Filling Your Prescriptions


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Getting a prescription filledYour Horizon BCBSNJ plan includes prescription drug coverageadministered by Prime Therapeutics, LLC (Prime).

HEALTH INSURANCE MARKETPLACE FORMULARY Horizon BCBSNJ maintains a covered drug list (formulary). The Pharmacyand Therapeutics (P&T) Committee, an independent group of doctors andpharmacists, manages the formulary. The drug list divides coveredmedicines into three levels (tiers):

This is only a guide to relative drug costs. Under some Horizon BCBSNJplans, cost sharing may be the same for drugs in two or all tiers. Please seeSection Eight: Your Policy for your plan’s prescription benefits, copaymentand/or coinsurance details.

The P&T Committee regularly reviews new and existing prescription drugsfor clinical effectiveness and patient safety. Drugs may be added or removed based on the Committee’s decisions. Also, a Tier 2 drug may bemoved to the costlier Tier 3 when a generic equivalent becomes available in Tier 1.

Online pharmacy servicesWith our online member tools, it’s easy to manage your prescriptionbenefits, view claims, research medicines and get started on home delivery.Sign in to Member Online Services at Members.HorizonBlue.com andselect Pharmacy Services to:

» Locate a nearby participating pharmacy.

» Look up prescription drug coverage and pricing.

» See and download the current prescription drug list.

» Set up convenient home delivery of maintenance medicines throughPrimeMail.

» Learn more about your medications and check for drug interactions

» Review the current prior authorization drug list.

» Find out any special requirements for medicines, such as whether ageneric must be used first.

Please note: Not all Horizon BCBSNJ members have Horizon BCBSNJ pharmacy benefits.Please read your Evidence of Coverage (EOC) to find out if this is part of your HorizonBCBSNJ benefits.

GENERIC OR BRAND NAME?The U.S. Food and DrugAdministration (FDA) regulatesgeneric drugs in the same wayas brand name drugs, so theyare just as safe and effective. Ifyour doctor prescribes a brandname drug, ask whether amoney-saving genericalternative would work for you.

If you have home delivery aspart of your pharmacycoverage and take medicine onan ongoing or regular basis,you may benefit fromPrimeMail®. This service canhelp you save time and moneyby having prescriptionsdelivered right to you.

To learn more about coveredprescription medicines, findinga participating pharmacy orPrimeMail, visitHorizonBlue.com/pharmacy,or call Pharmacy MemberServices at 1-800-370-5088.For home delivery customerservice, call PrimeMail at 1-888-844-3828.

Tier 3: Non-Preferredhighest cost

Tier 2: Preferred Brandmid-level cost

Tier 1: Generic lowest cost

SECTION SIX: Filling Your Prescriptions


Specialty pharmacy servicesSpecialty medicines require special patient education and monitoring, andthey may have restrictions on distribution and handling. Conditions thatmay require specialty medications include:

» Anemia

» Cancer

» Crohn’s Disease

» Cystic Fibrosis

» Growth Hormone Deficiency

» Hepatitis C

» Multiple Sclerosis

» Psoriasis

» Rheumatoid Arthritis

» Transplants/Immunosuppression

To support members who need specialty medicines, Horizon BCBSNJ hasagreements with pharmacies that specialize in delivering high levels ofservice, education and support for these specific specialty medicines.

EACH SPECIALTY PHARMACY OFFERS:» A pharmacist-led team that provides condition-specific education,

medication administration instruction and expert advice to help managetherapy

» Claims assistance to help determine individual coverage and filenecessary paperwork

» Easy access to pharmacists and other health experts 24 hours a day,seven days a week

» Simple ordering through a dedicated toll-free number

» Convenient, confidential delivery to the member’s chosen location(home, doctor’s office, vacation spot, etc.)

To minimize out-of-pocket costs, we encourage members to get theseprescription medicines from a participating specialty pharmacy. Due to theirnature and cost, all specialty pharmaceuticals are subject to a MedicalNecessity and Appropriateness Review.

For more information about specialty pharmaceuticals and participatingspecialty pharmacies, visit HorizonBlue.com/specialtyrx or call PharmacyMember Services at 1-800-370-5088.

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33

Prior authorization drug listSome medicines require prior authorization (PA) before they will be coveredby your plan and dispensed to you. PA means that your doctor must give usinformation to show the use of the medicine meets specific criteria. Thecriteria follow U.S. Food and Drug Administration (FDA)-approved productlabeling and generally accepted treatment guidelines to ensure safe andproper use of the medicine.

» The medicines requiring PA are listed on the following pages. This list iscomplete as of the date shown. Please note that new medicines come tomarket frequently. As a result, this list may be revised often.

» For the most current list of prescription medicines subject to PArequirements, log in to Member Online Services and select PharmacyServices. You can enter a medicine name to see if it has any specialrequirements, including PA. You can also call Pharmacy Member Servicesat 1-800-370-5088 to find out if a medicine requires PA.

» If your medicine requires PA, please ask your doctor to call Prime ClinicalReview at 1-888-214-1784 to begin the PA process. Your doctor can alsocomplete the PA electronically using the physician portal. Your plan willnot cover the medicine until the PA is approved.

» PA may also be required for brand name drugs when FDA-approved generic equivalents are available.

» The following PA drug list contains brand name products that areregistered marks or registered trademarks of brand manufacturers notaffiliated with either Horizon Blue Cross Blue Shield of New Jersey or theBlue Cross and Blue Shield Association.

This listing of prescription drugs that are subject to PA/Medical Necessityreview under your prescription coverage is complete as of the dateindicated. Please note that new medicines are coming to market withincreasing frequency and as a result this listing is subject to revision on aregular basis.



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DRUGS REQUIRING PRIOR AUTHORIZATION AS OF JULY 2, 2015



35

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36 MEMBER ONLINE SERVICES | MEMBERS.HORIZONBLUE.COM | 24 hours a day, seven days a week

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SEVEN

ImportantNotices


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Your rightsAs a Horizon BCBSNJ member, you have the right to:

» Be treated with courtesy and consideration, and with respect for yourprivacy and dignity.

» Get information about Horizon BCBSNJ services, policies, procedures,doctors, appeals and coverage limitations, as well as information aboutthe organization and care provided.

» Choose a Primary Care Physician (PCP) or participating doctor tocoordinate your care, to change your doctor selection, and to have 24/7doctor access for urgent or emergency care.

» Participate with your doctors in making decisions about your health care.

» Seek emergency care without prior approval in a potentially life-threatening situation or when you believe that serious harm couldresult from not obtaining immediate treatment.

» Get specialist and hospital care from appropriate participating providersfollowing an authorized referral (if required by your plan).

» Receive a written explanation if approval of a covered service is deniedor limited under your plan.

» Be free of “balance billing” for charges above the amount HorizonBCBSNJ allows for a participating service.

» Voice a concern about your plan and the care provided, includinginternal and external appeals.

Your responsibilitiesAs a Horizon BCBSNJ member, you have the responsibility to:

» Read and understand this About Your Benefits handbook, your policyand all other materials about your plan and coverage.

» Be considerate and courteous to doctors and staff.

» Coordinate non-emergency care through your participating doctor.

» Participate in your care by, to the extent possible, providing informationabout your health and following any care plans and instructions youagree on with your doctor.

» Pay for charges, including copayments, deductibles and coinsurance asstated in your plan, as well as for any charges you incur for non-coveredcare.

This is a partial list of your member rights and responsibilities. For acomplete list of rights and responsibilities, along with more informationabout your relationship with Horizon BCBSNJ, please visitHorizonBlue.com/rights or call Member Services. If you do not haveaccess to the Internet, you may call Horizon BCBSNJ’s Member Services atthe number on the back of your ID card for a copy of the Member Rightsand Responsibilities.

SECTION SEVEN: Important Notices


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How to make inquiries, complaints and appealsAt Horizon BCBSNJ, we’re dedicated to providing all our members withaccess to quality health care and service. Your plan offers inquiry, complaintand appeal processes designed to provide prompt response and resolutionto all requests.

These processes relate to:

» Medical issues

» Our utilization management decision making

» Other nonutilization management issues

Please refer to Section Eight: Your Policy for more details or call MemberServices.

Coordination of benefits with other health coverageIf you or a covered member of your family also has health coverage underMedicare or with any other insurer, you must let us know.

To avoid duplication of coverage, we coordinate your Horizon BCBSNJ planbenefits with those provided by the other insurer. Depending on yourpolicy, either Horizon BCBSNJ or your other insurer is considered primary.

» If your other plan is primary, claims go to that plan first. In this case,Horizon BCBSNJ’s coverage would be secondary – we consider eachclaim for payment after it has been processed by the other plan.

» If your Horizon BCBSNJ plan is primary, we process your claims firstwithout regard to any other insurance coverage.

» In any case, Horizon BCBSNJ won’t pay more for claims than we wouldhave if we had been your only health care plan.

To update your information, sign in to Member Online Services and clickUpdate Additional Insurance in the I Want To... section.

Please see Coordination of Benefits in Section Eight: Your Policy forcomplete details. If you have questions, call Member Services.



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Results of independent satisfaction surveysYou can get results of independent consumer satisfaction surveys andanalysis of quality outcomes for health care services provided undermanaged care plans in New Jersey.

Send your request to:

Actuarial BureauNew Jersey Department of Banking and Insurance20 West State Street, 11th FloorPO Box 325Trenton, NJ 08625-0325Or call:

1-609-292-5427

Continuation-of-care benefitsIf you are receiving covered services (other than obstetrical care, post-operative care, oncological treatment or psychiatric treatment) from aterminated health care professional who was under contract with us at thetime your treatment started, you may continue care or services with thathealth care professional for up to four months where medically necessary.

If you are receiving obstetrical care, post-operative care, oncologicaltreatment or psychiatric treatment from a terminated health careprofessional who was under contract with us at the time your treatmentstarted, you may continue to be treated by that health care professional forthe duration of the treatment or care:

» Pregnancy: Coverage of services will continue through the postpartumevaluation, up to six weeks after delivery.

» Post-operative follow-up care: Coverage of services may continue for upto six months from the date of the health care professional’s termination.

» Oncological treatment: Coverage of services may continue for up to oneyear from the date of the health care professional’s termination.

» Psychiatric treatment: Coverage of services may continue for up to oneyear from the date of the doctor or health care professional’stermination.

Note: These guidelines won’t apply if the health care professional isterminated immediately under any of these circumstances:

» In the opinion of Horizon BCBSNJ’s medical director, the health careprofessional is an imminent danger to a patient or the public health,safety and welfare.

» There has been a determination of fraud or a breach of contract by thehealth care professional.

» The health care professional is the subject of disciplinary action by theState Board of Medical Examiners.



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Please call Member Services if you have questions about your continuation-of-care benefits. As always, your benefits are subject to policylimits and normal Horizon BCBSNJ policies and procedures, including priorauthorization and utilization management requirements.

Medical technologyWe regularly review new medical technology to decide if it is eligible for coverage.

Our review incorporates input from the professional and medicalcommunity (including medical practitioners in New Jersey), as well as theresearch results published in the medical literature. We also review ourcurrent policies related to existing technology and amend them asappropriate.

Physician compensation In general, Horizon BCBSNJ pays participating doctors and other healthcare professionals in two ways:

» Fee for Service – Payment for services each time a member is seen or treated

» Capitation – Payment of a monthly per-patient fee, whether or not amember receives services in any given month

These payment methods may include financial incentive agreements.Doctors and other health care professionals may be paid more (rewards) orless (withholds) based on many factors, including member satisfaction,quality of care, control of costs and use of services (Horizon BCBSNJ doesnot have withholds as a method of payment).

You have the right to ask your doctor and other health care professionalsabout how they are compensated for their services by Horizon BCBSNJ soyou will know if there could be any financial incentives or disincentives tiedto their medical decisions.

Note: The laws of the state of New Jersey at N.J.S.A. 45:9-22.4 et seq.,require that a doctor, chiropractor or podiatrist, who is permitted to makereferrals to other health care professionals or facilities in which he or she hasa significant financial interest, inform his or her patients of that financialinterest when making such a referral.

For more information about compensation, ask your doctor or other healthcare professional. If you believe that you are not receiving the informationto which you are entitled, you may call the New Jersey Division ofConsumer Affairs at 1-800-242-5846 or 1-973-504-6200.



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Utilization managementHorizon BCBSNJ’s Utilization Management (UM) Program monitors yourhealth care – the care you receive and the care your doctor proposes foryou – to assess its medical necessity and appropriateness. Utilizationmanagement also lets us help doctors to manage the care they provide inmedically appropriate and cost-effective ways. Through UM, we identifybest practices that produce high-quality care and health outcomes, andshare that knowledge with members, participating doctors, health careprofessionals and employers through continuing education.

In particular, we watch for:

» Underutilization – Not getting annual checkups or preventivevaccinations as recommended

» Overutilization – Getting medical care, medications, laboratory testingor surgical procedures when they are not medically necessary

OUR UTILIZATION MANAGEMENT PRINCIPLES» We make UM decisions based only on the necessity and appropriateness

of care and services within the provisions of the member’s benefitpackage.

» We don’t compensate anyone responsible for UM decisions in a way thatrewards him or her for denying coverage for medically necessary andappropriate covered services.

» We don’t offer incentives to anyone responsible for UM determinationsto encourage denials of coverage or services, and we don’t providefinancial incentives to doctors to withhold covered health care servicesthat are medically necessary and appropriate.

» We emphasize the delivery of medically necessary, appropriate and cost-effective health care services to members, and we encourage thereporting, investigation and elimination of underutilization.

ABORTION COVERAGEThis plan covers certain abortion services. Please refer to Section Eight: Your Policy for more details or call Member Services.



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Notice of information privacy practicesHorizon Blue Cross Blue Shield of New Jersey and its affiliated companies*want you to know that we are legally obligated to keep information aboutyou secure and confidential. Unlike many other financial and healthinstitutions, we do not sell information about you and we do not share yourinformation except to conduct our business.

As required by law, we publish this Notice to explain the information thatwe collect and how we maintain, use and disclose it in administering yourbenefits. We will abide by the statements made in this Notice. Except aspermitted by law and as explained in this Notice, we do not disclose anyinformation about our past, present or future customers to anyone. Usesand disclosures not described in this Notice will be made only with yourwritten authorization. When we use the term "Customer Information," weare referring to financial or health information that is "nonpublic," includingany information from which a judgment could possibly be made about you.When we use the term "Protected Health Information" or "PHI," we arereferring to individually identifiable oral, written and electronic informationconcerning the provision of, or payment for, health care to you. We refer toCustomer Information and PHI collectively as "Private Information."

MEMBERS OF SELF-FUNDED PLANSIf you are a participant or beneficiary of a self-funded group health plan, wemay use and disclose your Private Information as described in this Notice.However, our use or disclosure is dictated by an arrangement with youremployer (or other sponsor of your benefits plan) or that plan itself. Thatplan may use and disclose your Private Information differently than isdescribed here. With respect to your individual rights, you should ask yourplan administrator how to exercise those rights, along with any otherquestions you may have regarding your plan’s privacy policies and practices.This Notice also applies to Horizon BCBSNJ’s employee health benefit plan.

WHAT INFORMATION DO WE COLLECT?In providing your health coverage, we collect Private Information from thefollowing sources:

» Information we receive from you or your policyholder on applications,other forms or websites we sponsor

» Information we obtain from your transactions with us, our affiliates orothers, such as health care providers

» Information we receive from consumer-reporting agencies or others,such as Medicare, state regulators and law enforcement agencies



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HOW DO WE PROTECT PRIVATE INFORMATION?Our employees are trained on the need to maintain your PrivateInformation in the strictest confidence. They agree to be bound by thatpromise of confidentiality and are subject to disciplinary action if theyviolate that promise. We also maintain appropriate administrative, technicaland physical safeguards to reasonably protect your Private Information.

In addition, in those situations where we rely on a third party to performbusiness, professional or insurance services or functions for us, that thirdparty must agree to safeguard your Private Information. That businessassociate must also agree to use it only as required to perform its functionsfor us and as otherwise permitted by our contract and the law. Finally, if weor our business associate causes a "breach" of privacy as that term isdefined under federal law, we will notify you without unreasonable delay ofthe occurrence. In these ways, we carry out our confidentiality commitmentsto you.

WHEN MUST WE SEEK YOUR AUTHORIZATION BEFORE DISCLOSING PRIVATE INFORMATION?There may be circumstances where we will seek your authorization beforemaking a disclosure of your Private Information. This is to ensure that wehave your permission to make that disclosure. For example, you may haveasked someone who is not your personal representative (or thepolicyholder) to contact us on your behalf to obtain information about yourclaims. Before we disclose your Private Information to that person, wewould seek your authorization to do so, unless otherwise permitted ordescribed in this Notice. Your written authorization is required for (1) usesand disclosures of Private Information for marketing activities, when suchauthorization is required by law; (2) uses and disclosures of psychotherapynotes; and (3) uses and disclosures that constitute a sale of your PrivateInformation.

If you give us your authorization, you are permitted to revoke thatauthorization at any time in writing. We will honor your revocation once it isprocessed, except to the extent that we have taken action in reliance uponyour original authorization, or the authorization was obtained as a conditionof obtaining coverage.



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USES AND DISCLOSURES OF PRIVATE INFORMATION THAT DO NOT REQUIRE AUTHORIZATIONMost of our routine use and disclosure of your Private Information occurs inadministering your coverage. In those instances, we are not required toseek your authorization. For instance, we are generally permitted to makedisclosures of your Private Information without authorization for purposes oftreatment, payment and health care operations. In this Notice, we provideexamples of those routine purposes, although not every use or disclosurethat falls into those categories is listed.

Please note that we will limit the disclosure of certain information inaccordance with laws governing the special nature of the information (e.g.,HIV/AIDS, substance abuse, genetic information). We are prohibited fromusing and disclosing your genetic information for underwriting purposes.Also, where a state permits minors of a certain age or status to seektreatment without parental consent, information that would normally beprovided to our customers may be limited, if requested, and we areinformed that treatment was rendered that way. That is because we mustprotect the privacy of that minor’s information in accordance with thosestate laws.

Payment ActivitiesWe routinely use and disclose Private Information in connection with yourhealth care coverage, to determine your eligibility for coverage andbenefits, and to see that the treatment and services you receive areproperly billed and paid. To do this, we may share Private Information withhealth care providers, their billing agents, insurance companies and others.Our payment activities can also include the use of Private Information for:risk adjustment, billing, claims management, collection activities, utilizationreview, medical necessity determinations, drug rebate contract reporting ofdrug utilization, underwriting and other rate-setting activities.

For example, a claim for medical services rendered to you may besubmitted electronically from a billing service on behalf of your provider.Our claims processors will then use your Private Information to process yourclaim. If we need additional information to process it, we may contact yourprovider to obtain that information. When we do that, we disclose PrivateInformation to your provider in order to identify and discuss your claim withhim or her. Your provider then discloses the needed, additional PrivateInformation that will enable us to properly process your claim. In thisexample, each of these entities involved – your provider, his or her billingservice and Horizon BCBSNJ and/or its affiliated companies – is covered byand must protect and safeguard your Private Information either becausethey are "covered entities" or "business associates" of covered entitiesunder the federal privacy regulations.



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Health Care Operations Activities We routinely use and disclose Private Information to conduct our healthcare business, including all the activities that are defined by federalregulation as "health care operations." They include, but are not limited to:case management and care coordination, utilization review, qualityassessment and improvement, network provider credentialing, population-based research to improve health or reduce health care costs,and contacting providers and members with information about treatmentalternatives.

For example, we may use and disclose Private Information to remind youabout the availability or value of preventive care or of a diseasemanagement program. Other health care operations activities includecompliance and auditing activities, evaluating provider performance,underwriting, formulary development, information systems management,fraud and abuse detection (by ourselves or for other plans or providers),facilitation of a sale, transfer, merger or consolidation of all or part ofHorizon BCBSNJ and/or its affiliated companies with another entity(including due diligence related to the transaction), customer service andgeneral business management, among others.

Health-Related ActivitiesWe may use or disclose your Private Information for a number of treatment-related activities. We are permitted to tell you about possibletreatment options or alternatives, inform you of health-related benefits orservices, inform you of a relevant disease management program that maybe of interest to you, and seek your voluntary participation in such programsto help improve your health and assist in the coordination of your overallhealth care. For example, our diabetes disease management businessassociate may, after reviewing PHI that we had provided, determine thatyou might suffer from diabetes. You may then receive a notice that we haveenrolled you in our disease management program. If you do not wantfurther contact about, or to participate in, the program, you only need tonotify us. Our business associate would then be instructed to not use ordisclose your information further, which it must follow due to its contractwith us.

Treatment, Payment and Health Care Operations of Other Covered EntitiesWe may use and disclose your PHI for another covered entity’s treatment,payment and health care operations purposes. For example, we maydisclose your PHI when disclosure would facilitate payment for servicesunder another health plan. In addition, we are permitted to disclose PHI toother covered entities so they can conduct certain aspects of their healthcare operations. We may also disclose it for purposes of their fraud andabuse detection or compliance. But we will only disclose PHI to anothercovered entity for these purposes if that covered entity has or had arelationship with you.



Disclosures to Family MembersUnless you notify us in writing otherwise, we may disclose your PrivateInformation to certain other family members who are on your coverage. Inthe context of spouse-to-spouse (or between civil union partners) andparent-to-child relationships, including both minor and adult children, wewill deem the spouse/civil union partner or parent on their coverage to bethe personal representative of the other spouse/civil union partner and/orthe child, as applicable. We will do this unless you notify us in writing thatyou do not wish that individual to serve as your personal representative.Contact Member Services as described in this Notice to designate orterminate a personal representative involved in your care or coverage.

Under certain exceptional circumstances, such as a medical emergency, wemay disclose your Private Information to a person who is involved in yourcare or payment for that care. We can only disclose your Private Informationthat is relevant to that person’s involvement with your care or payment forthat care.

Additional Reasons for DisclosureWe may also use or disclose Private Information to:» The certificate holder or policyholder of your coverage, if it is information

regarding the status of an insurance transaction, as permitted by law;

» Military authorities, if you are or were a member of the armed forces;

» Further public safety or, when requested by federal officials, for nationalsecurity or intelligence activities or for the protection of public officials;

» Appropriate bodies for public health activities, including the reporting ofchild abuse or neglect, adverse events, product defects, or for Food andDrug Administration reporting;

» A health oversight agency for activities such as audits, investigations,licensure, disciplinary actions, or civil, administrative or criminalproceedings. These disclosures are necessary for the government tooversee the health care system and government benefits programs, aswell as for compliance with standards and civil rights laws;

» Carry out appropriate research, but only as expressly permitted andlimited by the federal privacy rules;

» Communicate with legislators and regulators about legislative andregulatory developments and proposals that may impact access toaffordable, quality health care;

» Contact you for fundraising purposes. You have the right to opt out ofreceiving fundraising communications;

» Appropriate bodies in response to a subpoena or court order, or inresponse to litigation that directly involves us or your group health plan;

» A correctional institution or law enforcement agency, if you are an inmateor in the custody of law enforcement;

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» Plan sponsor employees that are designated by the plan administrator asassisting in plan administration. The federal privacy rules require yourplan administrator to obtain certain representations from the plansponsor about how your information will be protected. This is to ensurethat the plan sponsor complies with certain privacy requirements andagrees not to use that information for employment-related and otherdecisions;

» Conduct permissible marketing-type activities, either ourselves orthrough other companies on our behalf, such as for health-relatedproducts or services, or to other financial and health institutions withwhich we have joint marketing agreements;

» Perform other functions and activities, as permitted by the federalprivacy rules.

You should understand that, except as permitted or described in thisdocument, we will not disclose your Private Information without a writtenauthorization from you. And except for disclosures of PHI made directly toyou or your personal representative, for your treatment, or pursuant to yourauthorization, the federal rules require us to use and disclose only theminimum PHI necessary to accomplish our purpose. For example, if weneed to disclose your PHI to our utilization review case manager to helpdetermine the medical necessity of a particular claim, we would likely notdisclose your entire claim history and medical record. That is because yourentire record is probably not necessary to make the determination for thatone claim.

Legal Rights Related to PI The federal privacy rules entitle you to:

» Inspect and obtain a copy of your PHI that we maintain about you that isincluded in what is called a “designated record set”. This includes yourright to request access to PHI in an electronic format if we hold it thatway. But we are not required to maintain it, except for certaindocumentation related to privacy rules compliance or as may otherwisebe required by law.

This does not include information that relates to, and is collected inconnection with or in anticipation of, a claim or civil or criminalproceeding involving you. It also does not include information which weare prohibited by law from releasing. You must reasonably describe theinformation you seek in your written request, and the information mustbe reasonably locatable and retrievable by us. We may charge you a feeto cover the cost of providing this Private Information. Information isusually provided within 30 days of your request.

You may have a state law right to request, in writing, to inspect andobtain a copy of Private Information about you.

» The federal privacy rules create a right to request amendment of yourPHI included in the designated record set. We may deny your requestunder those rules if we determine that our records are accurate andcomplete or were not created by us, the information is not contained inour designated record set, or access is otherwise restricted by law.



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State law may entitle you to request that we amend or delete PrivateInformation about you in our records if you believe the information isincorrect or incomplete. We may deny this request. However, if we do so,we must advise you of the reasons for the denial and advise you of yourright to file a statement of rebuttal.

» The federal privacy rules entitle you to request restrictions on our useand disclosure of PHI for treatment, payment or health care operations(described in this Notice). We will consider each request, but are notrequired to agree to any restrictions, except a reasonable request forconfidential communications.

» The federal privacy rules entitle you to request to receive confidentialcommunications of PHI if disclosing this information by the usual meanscould endanger you. We will accommodate all reasonable requests,subject to the restrictions and capabilities of our information processingsystems. A verbal request may be considered, but must be followed upin writing.

» The federal privacy rules entitle you to request to receive an accountingof certain disclosures of your PHI made by us, such as disclosures tohealth oversight agencies. These do not include disclosures made forpurposes of treatment, payment or health care operations, disclosures toyou or authorized by you, and for certain other reasons. A similar rightmay exist under state law.

» You have the right to request and obtain a paper copy of this Notice,even if you previously agreed to receive it electronically.

If you wish to exercise any of the legal rights described in this Notice, youmust do so in writing. To obtain further information about these rights, or ifyou would like to make such a request, please contact either:

Horizon BCBSNJ Member ServicesPO Box 820Newark, NJ 07101-0820orCall: 1-800-355-BLUE (2583)

Keeping Up to Date with Our Privacy PracticesHorizon BCBSNJ and its affiliated companies reserve the right to changethe terms of this Notice and to make the new Notice provisions effectivefor all information that we maintain. Our policies may change as weperiodically review and revise them. We will provide you with a new Noticeif the changes are significant. A copy of our Notice can be found atHorizonBlue.com, under the section titled Privacy Policy. We will alsoprovide you with a Notice of Information Privacy Practices (or a summary ofthe Notice) annually, as long as you maintain an ongoing insured customerrelationship with us.

It may be necessary to use or disclose your Private Information asdescribed in this Notice even after coverage has terminated. In addition, itmay be infeasible to destroy your private information. Thus, we do notnecessarily destroy it upon the termination of your coverage. However, anyinformation we keep must be kept secure and private, and used only forpermissible purposes.


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ComplaintsIf you believe that your privacy rights have been violated, you may file acomplaint with Horizon BCBSNJ and its affiliate companies by callingMember Services at 1-800-355-2583 (BLUE), or by writing to:

Horizon BCBSNJ Privacy OfficeThree Penn Plaza East, PP-16FNewark, NJ 07105-2200You may also complain to the U.S. Secretary of Health and Human Services.You will not be retaliated against for filing a complaint.

All complaints must be submitted in writing. A verbal complaint will beprocessed, but we request that it be documented in writing. If you haveany questions regarding the content of this Notice, you may call the Privacy Office at 1-973-466-5781.

* The Horizon Blue Cross Blue Shield of New Jersey affiliated companies,all of which are independent licensees of the Blue Cross and Blue ShieldAssociation, are:

Horizon Healthcare Services, Inc. d/b/a/ Horizon Blue Cross Blue Shield ofNew Jersey.

Horizon Healthcare of New Jersey, Inc., including its Horizon NJ Health(Medicaid/NJ FamilyCare) line of business.

Horizon Insurance Company

Horizon Healthcare Dental, Inc.

Horizon Casualty Services, Inc.**

** This affiliate is not a covered entity subject to the federal privacy rules.

Women’s Health and Cancer Rights Act of 1998Under federal legislation, notification of this benefit is required to allmembers.

In 1998, the federal government enacted a law that mandates certain healthcoverage for breast reconstructive surgery in any health program thatprovides medical and surgical benefits for mastectomies. This law is knownas The Women’s Health and Cancer Rights Act.

If a covered person is receiving benefits in connection with a mastectomyand elects to have breast reconstruction along with that mastectomy, thepolicy must provide in a manner determined in consultation with theattending physician and the patient, coverage for the following:

» All stages of reconstruction of the breast on which the mastectomy wasperformed;

» Surgery and reconstruction of the other breast to produce a symmetricalappearance; and

» Prostheses and physical complications at all stages of the mastectomy,including lymphedemas.





These benefits will be provided subject to deductibles and coinsurance tothe same extent as for any other illness under your coverage.

All other features and benefits of this program remain the same and are notimpacted by this notification.

Horizon Blue Cross Blue Shield of New Jersey is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross® and Blue Shield® names and symbols and BlueCard® are registered marks of the Blue Cross and Blue Shield Association. The Horizon® name, symbols and PRECIOUS ADDITIONS® are registered marks, and OMNIASM, Horizon ConnectSM, Horizon CareOnlineSM andHorizon Behavioral HealthSM are service marks of Horizon Blue Cross Blue Shield of New Jersey.AndroidTM and Google PlayTM are trademarks of Google, Inc.iPhone® is a digital mobile device and is a registered mark, and AppStoreSM is a service mark of Apple, Inc.Prime Therapeutics LLC is an independent company administering pharmacy benefits.WebMD® is a registered mark of WebMD, LLC.YouTubeTM is a trademark of Google, Inc.All other trademarks are the properties of their respective owners.© 2016 Horizon Blue Cross Blue Shield of New Jersey.Three Penn Plaza East, Newark, New Jersey 07105.

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