JUNE 2017 | horizonNJhealth.com | Member Services: 1-800-682-9090 (TTY/TDD 711) 1

What Horizon
NJ Health Covers BENEFIT PLAN TYPE
BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D
Abortions & Related Services Covered by Fee-for-Service

Acupuncture Covered when provided by a licensed doctor

Coverage is limited
to when performed as
a form of anesthesia
in connection with
covered surgery by a
licensed doctor

Audiology Covered Covered for members under the age of 16

Blood & Blood Plasma Covered

Coverage is limited
to administration
of blood, processing
of blood, processing
fees and fees related
to autologous blood
donations

Chiropractic Services Coverage is limited to spinal manipulation
Coverage is limited
to spinal manipulation
with a $5 copayment

Not Covered

Member Benefits and Services
As a member of Horizon NJ Health, you get the benefits
and services you are entitled to with the NJ FamilyCare Program.
The medical care and services you get through Horizon NJ Health
are free or low cost. Your benefit package is determined by the
NJ FamilyCare Program based on your income level and the
number of people in your family.

If you are not sure whether a service is covered, just call
Member Services and ask. Call toll free at 1-800-682-9090
People with hearing or speech difficulties can use our
TTY/TDD service at: 711.



JUNE 2017 | horizonNJhealth.com | Member Services: 1-800-682-9090 (TTY/TDD 711) 2

What Horizon
NJ Health Covers BENEFIT PLAN TYPE
BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D

Cognitive
Rehabilitation
Therapy

Covered Coverage limited to 60 visits per therapy, per incident, per calendar year

Coverage is limited
to treatment for non-
chronic conditions and
acute illnesses and injuries.
Limited to 60 visits per
therapy, per incident,
per calendar year

Dental
Covered for diagnostic and preventive services. The following major services
require Prior Authorization: crowns, bridges, full dentures, partial dentures, gum
treatments, root canal, extractions, complex oral surgery and orthodontics.

Covered with a $5 copayment, except for diagnostic
and preventive services.
The following major services require Prior Authorization:
crowns, bridges, full dentures, partial dentures, gum
treatments, root canal, extractions, complex oral surgery
and orthodontics.

Diabetic Supplies & Equipment Covered

Durable Medical Equipment
& Assistive Technology Devices Covered

Coverage is limited
to specific equipment.
Talk to your doctor or
call Member Services
for more information

Emergency Medical Care/
Emergency Services Covered

Covered with a
$10 copayment for
Emergency Room
services

Covered with a $35
copayment for Emergency
Room services, except
when referred by a PCP for
services that should have
been provided in the PCP?s
office or when admitted
to the hospital

EPSDT
(Early & Periodic Screening,
Diagnosis & Treatment)

Covered, including medical exams, dental, vision, hearing and lead screening services.
Covered for treatment services identified through the exam

Coverage is limited to
well-child care, newborn
hearing screenings,
immunizations and lead
screening and treatment



JUNE 2017 | horizonNJhealth.com | Member Services: 1-800-682-9090 (TTY/TDD 711) 3

What Horizon
NJ Health Covers BENEFIT PLAN TYPE
BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D

Family Planning
Covered. Covered by Fee-for-Service when services are not given by a Horizon NJ Health doctor.
Coverage includes medical history and physical exams (including pelvic and breast), diagnostic
and lab tests, drugs and biologicals, medical supplies and devices, counseling, continuing
medical supervision, continuity of care and genetic counseling.

Covered. Coverage
includes medical history
and physical exams
(including pelvic and
breast), diagnostic and
lab tests, drugs and
biologicals, medical
supplies and devices,
counseling, continuing
medical supervision,
continuity of care and
genetic counseling.
Must use Horizon
NJ Health participating
network providers

Group Homes & DCPP
Residential Treatment Facilities Covered Not Covered

Hearing Aid Services Covered Covered for members under the age of 16

Home Health Agency Services
Covered, including nursing services by a registered nurse and/or licensed practical nurse;
home health aide service; medical supplies and equipment; physical, occupational and speech
therapy services; pharmaceutical services; and durable medical equipment

Coverage is limited
to skilled nursing
provided or supervised
by a registered nurse
and home health aide
when the purpose of
the treatment is skilled
care. Coverage includes
medical social services
necessary for treatment
of the member?s
medical condition



JUNE 2017 | horizonNJhealth.com | Member Services: 1-800-682-9090 (TTY/TDD 711) 4

What Horizon
NJ Health Covers BENEFIT PLAN TYPE
BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D

Hospice Services
Covered in the community as well as in institutional settings. Room and board are included
only when services are delivered in an institutional (non-private residence) setting.
Hospice care for children under age 21 shall cover both palliative and curative care

Covered in the
community as well as in
institutional settings.
Room and board are
included only when
services are delivered
in an institutional
(non-private residence)
setting. Hospice care shall
cover both palliative and
curative care

Hospital Services (Inpatient) Covered

Hospital Services (Outpatient) Covered Covered with a $5 copayment, except for preventive services

Intermediate Care Facilities/
Intellectual Disability Covered by Fee-for-Service Not Covered

Laboratory Services Covered, including routine testing related to the administration of atypical antipsychotic drugs

Covered, including routine
testing related to the
administration of atypical
antipsychotic drugs, with
a $5 copayment when not
part of an office visit

Maternity Services Covered, including related newborn care and hearing screening

Medical Day Care Covered Not Covered

Medical Supplies Covered
Limited coverage. Talk to
your doctor or call Member
Services for more information



JUNE 2017 | horizonNJhealth.com | Member Services: 1-800-682-9090 (TTY/TDD 711) 5

What Horizon
NJ Health Covers BENEFIT PLAN TYPE
BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D

Mental Health Inpatient
Hospital Services (Including
Psychiatric Hospitals)

Covered for DDD and MLTSS members by Horizon
NJ Health. Non-DDD members are covered by
Fee-for-Service

Covered for DDD members by Horizon NJ Health.
Non-DDD members are covered by Fee-for-Service Covered by Fee-for-Service

Mental Health Outpatient
Services (Excluding Partial
Care Services)

Covered for DDD and MLTSS members by Horizon
NJ Health. Non-DDD members are covered by
Fee-for-Service

Covered for DDD members by Horizon NJ Health.
Non-DDD members are covered by Fee-for-Service Covered by Fee-for-Service

Mental Health ? Home Health
Covered for DDD and MLTSS members by Horizon
NJ Health. Non-DDD members are covered by
Fee-for-Service

Covered for DDD members by Horizon NJ Health.
Non-DDD members are covered by Fee-for-Service

Methadone (Maintenance
and Administration) Covered by Fee-for-Service

Nurse Midwife Covered
Covered with a
$5 copayment for
each visit, except for
prenatal care visits

Covered with a $5
copayment for the first
prenatal care visit. $10
copayment for services
rendered during non-office
hours. No copayment for
preventive services for
newborns covered under
Fee-for-Service

Nurse Practitioner Covered
Covered with a
$5 copayment for
each visit, except for
preventive care services

Covered with a $5
copayment for each visit
during office hours, except
for preventive care services.
$10 copayment for visits
during non-office hours



JUNE 2017 | horizonNJhealth.com | Member Services: 1-800-682-9090 (TTY/TDD 711) 6

What Horizon
NJ Health Covers BENEFIT PLAN TYPE
BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D
Nursing Facility Services
(Custodial Care, Rehabilitation,
Post-acute Care, Skilled
Nursing Care and Services
in Special Nursing Facilities,
Such as Ventilator Facilities,
Pediatric Long-term Care
and Treatment for AIDS)

Covered Covered Covered, No Custodial Care Not Covered

Optical Appliances

Covered for select eyeglasses and contact lenses as follows:
? Age 18 and under and 60 and older ? Replacement eyeglasses or contact lenses annually if prescription changes
? Age 19 to 59 ? Replacement eyeglasses or contact lenses every two years if prescription changes

Replacement eyeglasses or contact lenses may be dispensed more frequently if significant vision changes occur.
Contact lens exams and fittings are covered only when deemed medically necessary over glasses.

Optometrist Services Covered for one routine eye exam per year Covered for one routine eye exam per year with a $5 copayment
Organ Transplants Covered for transplant-related medical costs for the donor and recipient.

Orthodontic Services
Coverage is limited to members up to age 19 who require these
services due to medical need, including developmental problems
or jaw injury. Prior authorization required.

Coverage is limited
to members up to
age 19 who require
these services due to
medical need, including
developmental
problems or jaw injury,
with a $5 copayment.
Prior authorization
required.

Coverage is limited to
members up to age 19 who
require these services due
to medical need, including
developmental problems
or jaw injury, with a $5
copayment. Prior
authorization required.

Orthotics Covered Not Covered
Outpatient Diagnostic Testing Covered
Partial Care Program Covered by Fee-for-Service Not Covered



JUNE 2017 | horizonNJhealth.com | Member Services: 1-800-682-9090 (TTY/TDD 711) 7

What Horizon
NJ Health Covers BENEFIT PLAN TYPE
BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D
Partial Hospital Program Covered by Fee-for-Service Not Covered
Personal Care Assistant Services Covered Not Covered
Personal Preference
Program Services Covered Not Covered

Podiatrist Services
Covered. Routine hygienic care of feet, including the treatment of corns
and calluses, trimming of nails and other hygienic care in the absence
of a pathological condition, is not covered.

Covered with a $5 copayment. Routine hygienic
care of feet, including the treatment of corns and
calluses, trimming of nails and other hygienic care in
the absence of a pathological condition, is not covered.

Prescription Drugs
(Retail Pharmacy)

Covered, including atypical antipsychotics, Suboxone and Subutex
or any other drug within this category when used for the treatment
of opioid dependence (except methadone which is covered Fee-for-Service),
and drugs that may be excluded from Medicare Part D coverage.
No coverage for erectile dysfunction drugs and drugs not covered by
a third-party Medicare Part D formulary

Covered with a $1
copayment for generic
drugs and a $5
copayment for brand-
name drugs. Includes
atypical antipsychotics,
Suboxone and Subutex
or any other drug within
this category when
used for the treatment
of opioid dependence
(except methadone
which is covered Fee-
for-Service), and drugs
that may be excluded
from Medicare Part D
coverage. No coverage
for erectile dysfunction
drugs and drugs not
covered by a third
party Medicare Part D
formulary

Covered with a $5
copayment for brand-
name and generic drugs.
If greater than a 34-day
supply, a $10 copayment
applies. Includes atypical
antipsychotics, Suboxone
and Subutex or any
other drug within this
category when used for
the treatment of opioid
dependence (except
methadone which is
covered Fee-for-Service),
and drugs that may be
excluded from Medicare
Part D coverage. No
coverage for over-the-
counter drugs, erectile
dysfunction drugs and
drugs not covered by a
third party Medicare Part
D formulary

Prescription Drugs (Medicare
Part B Doctor-Administered) Covered



JUNE 2017 | horizonNJhealth.com | Member Services: 1-800-682-9090 (TTY/TDD 711) 8

What Horizon
NJ Health Covers BENEFIT PLAN TYPE
BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D

Primary Care, Specialty Care
and Women?s Health Services Covered

Covered with
a $5 copayment
for each visit.
No copayment
for well-child visits,
lead screening/
treatment,
age-appropriate
immunizations,
prenatal care or
Pap smears

Covered with a $5
copayment for each
visit during office hours.
$10 copayment for each
visit during non-office
hours. No copayment
for well-child visits, lead
screening/treatment,
age-appropriate
immunizations or
preventive dental
services.

$5 copayment for first
prenatal visit, then no
subsequent copayments

Private Duty Nursing Covered for members under age 21 Covered if authorized by Horizon NJ Health

Prosthetics Covered

Coverage is limited to
the initial provision
of a prosthetic device
that temporarily or
permanently replaces all
or part of an external body
part lost or impaired as a
result of disease, injury or
congenital defect.

Repair and replacement
services are covered
only when needed due
to congenital growth



JUNE 2017 | horizonNJhealth.com | Member Services: 1-800-682-9090 (TTY/TDD 711) 9

What Horizon
NJ Health Covers BENEFIT PLAN TYPE
BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D

Radiology Services
(Diagnostic & Therapeutic) Covered

Covered with a $5
copayment when
not part of an office visit

Rehabilitation Services
(Outpatient Physical Therapy,
Occupational Therapy and
Speech Therapy)

Covered Covered for 60 visits per therapy, per incident, per calendar year

Covered with a $5
copayment; limited to
60 visits per therapy, per
incident, per calendar
year. Speech therapy
for developmental
delay, unless resulting
from disease, injury or
congenital defects, is
not covered. Cognitive
rehabilitation therapy
services limited to
treatment for non-chronic
conditions and acute
illnesses and injuries

Sex Abuse Examinations
and Related Diagnostic Testing Covered by Fee-for-Service

Social Necessity Days Covered by Fee-for-Service; limited to no more than 12 inpatient hospital days Not Covered

Specialty Foods (Medical Foods)
Coverage is limited to nutritional supplements requiring medical supervision for members
with inborn errors of metabolism and related genetic conditions. Medical foods and special diets
for all other medical conditions are not covered

Not Covered



JUNE 2017 | horizonNJhealth.com | Member Services: 1-800-682-9090 (TTY/TDD 711) 10

What Horizon
NJ Health Covers BENEFIT PLAN TYPE
BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D

Substance use
(Inpatient and Outpatient)

Covered for DDD
members by Horizon
NJ Health. Medically
managed detox in an
acute care setting is
covered by Horizon
NJ Health

Covered for DDD
members by Horizon
NJ Health. Medically
managed detox in an
acute care setting is
covered by Horizon
NJ Health Non-DDD
members are covered
by Fee-for-Service.

Covered for DDD members by Horizon NJ Health. Medically managed
detox in an acute care setting is covered by Horizon NJ Health

Substance use (Day Treatment/
Partial Hospitalization) Covered by Fee-for-Service Not Covered

Substance use (Outpatient a
nd Intensive Outpatient) Covered by Fee-for-Service Not Covered

Substance use
(Residential ? Halfway House
and Short-term Residential)

Covered by Fee-for-Service Not Covered

Sub-acute Medically Managed
Detoxification and Enhanced
Medically Managed Detoxification

Covered by Fee-for-Service Not Covered

Transportation Services ?
Emergency Ambulance (911) Coverage is limited to ambulance for medical emergencies only

Transportation to Medically
Necessary Services

Covered by Fee-for-Service through LogistiCare.
To schedule, call LogistiCare at 1-866-527-9933 (TTY/TDD 1-866-288-3133). Not Covered

Transportation ? Livery
Services (Bus and Train Fare or
Passes, Car Service, Mileage
Reimbursement) to Medically
Necessary Services

Covered by Fee-for-Service through LogistiCare.
To schedule, call LogistiCare at 1-866-527-9933
(TTY/TDD 1-866-288-3133).

Contact LogistiCare at 1-866-527-9933
(TTY/TDD 1-866-288-3133). Not Covered



JUNE 2017 | horizonNJhealth.com | Member Services: 1-800-682-9090 (TTY/TDD 711) 11

? All services not medically necessary, provided, approved or
arranged by a Horizon NJ Health participating doctor (within
his or her scope of practice) except emergency services

? Any service or items for which a provider does not
normally charge

? Any service covered under any other insurance policy or
other private or governmental health benefit system
or third-party liability

? Cosmetic surgery except when medically necessary
and approved

? Experimental procedures, or procedures not accepted as
being effective, including experimental organ transplants

? Infertility diagnoses and treatment services (including
sterilization reversals and related medical and clinic office
visits, drugs, laboratory services, radiological and diagnostic
services and surgical procedures)

? Services provided by or in an institution run by the federal
government, such as the Veterans Health Administration

? Respite care

? Rest cures, personal comfort, convenience items and services
and supplies not directly related to the care of the patient.
Examples include guest meals and telephone charges

? Services in which health care records do not reflect the
requirements of the procedure described or procedure
code used by the provider

? Services involving the use of equipment in facilities in which its
purchase, rental or construction has not been approved by the
State of New Jersey

? Services or items reimbursed based on submission of a cost
study in which there is no evidence to support the costs allegedly
incurred or beneficiary income to make up for these costs. If
financial records are not available, a provider may verify costs or
available income using other evidence that the NJ FamilyCare
program accepts.

? Services provided by an immediate relative or household member

? Services provided in an inpatient psychiatric institution, that is not
an acute care hospital, to those over 21 years of age and under
65 years of age

? Services provided or started while on active duty in the military

? Services provided outside the United States and its territories

? Services provided without charge. Programs offered free of
charge through public or voluntary agencies should be used to
the fullest extent possible

? Services resulting from any work-related condition or
accidental injury when benefits are available from any workers?
compensation law, temporary disability benefits law, occupational
disease law or similar law

Services not covered by NJ FamilyCare
or Horizon NJ Health



JUNE 2017 | horizonNJhealth.com | Member Services: 1-800-682-9090 (TTY/TDD 711) 12

? Acupuncture and acupuncture therapy, except when
performed as a form of anesthesia in connection
with covered surgery

? Audiologist services, except for children under 16 years

? Biofeedback

? Blood and Blood Plasma, except administration of blood,
processing of blood, processing fees and fees related
to autologous blood donations are covered

? Chiropractic services

? Cosmetic services
? Court-ordered services
? Custodial care
? Early and periodic screening, diagnostic and treatment

(EPSDT) services (except for well child care, including
immunizations between screening/treatments)

? Experimental and investigational services

? Hearing Aid services, except for children under 16 years

? Infertility services
? Intermediate care facilities/intellectual disability
? Managed long term services and supports (MLTSS) not

otherwise listed above

? Medical day care services
? Non-medically necessary services
? Nursing facility services
? Orthotic devices
? Personal care assistant services
? Private duty nursing unless authorized by Horizon NJ Health
? Radial keratotomy

? Recreational therapy

? Rehabilitative services for substance use
? Religious non-medical institutions care and services
? Residential treatment center psychiatric programs

? Respite care

? Sleep therapy

? Special remedial and educational services

? Thermograms and thermography

? Transportation services, including non-emergency ambulance,
invalid coach and lower mode transportation

? Weight reduction programs or dietary supplements, except
surgical operations, procedures or treatment of obesity when
approved by Horizon NJ Health

Services not covered by NJ FamilyCare
or Horizon NJ Health for NJ FamilyCare D

Horizon NJ Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, gender, national origin, age, disability, pregnancy, gender identity,
sex, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations. Spanish (Espa?ol): Para ayuda en espa?ol, llame al 1-800-682-9090
(TTY/TDD 711). Chinese (??)??????????? 1-800-682-9090 (TTY/TDD 711)?
Horizon NJ Health is part of the Horizon Blue Cross Blue Shield of New Jersey enterprise, an independent licensee of the Blue Cross and Blue Shield Association.
? 2017 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105.



July 2019 | Member Services: 1-800-682-9090 (TTY 711)

What Horizon
NJ Health Covers BENEFIT PLAN TYPE
BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D
Abortions & Related Services Covered by Fee-for-Service

Acupuncture Covered when provided by a licensed doctor

Audiology Covered

Blood & Blood Plasma Covered

Chiropractic Services Covered Covered with a $5 copayment

Cognitive Rehabilitation Therapy Covered

Comprehensive Dental Benefits

There is no copayment for diagnostic and preventive services. The
following covered services require Prior Authorization: crowns, bridges,
full dentures, partial dentures, gum treatments, root canals, surgical
extractions, complex oral surgery, implants when medically necessary
to support a complete denture, and orthodontics. Access to dental
treatment in a hospital or surgical center is based on medical diagnosis.

Covered with a $5 copayment, except for diagnostic
and preventive services. The following services
require Prior Authorization: crowns, bridges, full
dentures, partial dentures, gum treatments, root
canals, surgical extractions, complex oral surgery,
implants when medically necessary to support
a complete denture, and orthodontics. Access to
dental treatment in a hospital or surgical center is
based on medical diagnosis.

Member Benefits and Services
Effective April 1, 2019
As a member of Horizon NJ Health, you get the benefits and services you are entitled to with the NJ FamilyCare Program. The medical care
and services you get through Horizon NJ Health are free or low cost. Your benefit package is determined by the NJ FamilyCare Program
based on your income level and the number of people in your family.
We want you to understand the services you can get with your benefits. If you are not sure whether a service is covered, just call Member
Services and ask. Call toll free at 1-800-682-9090. People with hearing or speech difficulties can use our TTY service at: 711.

DDD=Division of Developmental Disabilities FIDE-SNP=Horizon NJ TotalCare (HMO SNP) MLTSS=Managed Long Term Services & Supports
1



July 2019 | Member Services: 1-800-682-9090 (TTY 711) 2

What Horizon
NJ Health Covers BENEFIT PLAN TYPE
BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D
Diabetic Supplies & Equipment Covered

Durable Medical Equipment
& Assistive Technology Devices Covered

Emergency Medical Care/
Emergency Services Covered

Covered with a $10
copayment for
Emergency Room
services

Covered with a $35
copayment for Emergency
Room services, except
when referred by a PCP for
services that should have
been provided in the PCP?s
office or when admitted
to the hospital

EPSDT
(Early & Periodic Screening,
Diagnosis & Treatment)

Covered, including medical exams, dental, vision, hearing and lead screening services. Covered for treatment services identified
through the exam

Family Planning
Covered. Covered by Fee-for-Service when services are not given by a Horizon NJ Health doctor. Coverage includes medical history and
physical exams (including pelvic and breast), diagnostic and lab tests, drugs and biologicals, medical supplies and devices, counseling,
continuing medical supervision, continuity of care and genetic counseling.

Group Homes & DCPP
Residential Treatment Facilities Covered

Hearing Aid Services Covered

Home Health Agency Services Covered, including nursing services by a registered nurse and/or licensed practical nurse; home health aide service; medical supplies and equipment; physical, occupational and speech therapy services; pharmaceutical services; and durable medical equipment

Hospice Services Covered in the community as well as in institutional settings. Room and board are included only when services are delivered in an institutional (non-private residence) setting. Hospice care for children under age 21 shall cover both palliative and curative care.

Hospital Services (Inpatient) Covered

DDD=Division of Developmental Disabilities FIDE-SNP=Horizon NJ TotalCare (HMO SNP) MLTSS=Managed Long Term Services & Supports



July 2019 | Member Services: 1-800-682-9090 (TTY 711) 3

What Horizon
NJ Health Covers BENEFIT PLAN TYPE
BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D

Hospital Services (Outpatient) Covered Covered with a $5 copayment, except for preventive services
Intermediate Care Facilities/
Intellectual Disability Covered by Fee-for-Service Not Covered

Laboratory Services Covered, including routine testing related to the administration of atypical antipsychotic drugs

Maternity Services Covered, including related newborn care and hearing screening

Medical Day Care Covered Not Covered

Medical Supplies Covered

Nurse Midwife Covered Covered with a $5 copayment for each visit, except for prenatal care visits

Nurse Practitioner Covered Covered with a $5 copayment for each visit, except for preventive care services
Nursing Facility Services
(Custodial Care, Rehabilitation,
Post-acute Care, Skilled
Nursing Care and Services
in Special Nursing Facilities,
Such as Ventilator Facilities,
Pediatric Long-term Care
and Treatment for AIDS)

Covered Covered, No Custodial Care

Optical Appliances

Covered for select eyeglasses and contact lenses as follows:

? Age 18 and under and 60 and older ? Replacement eyeglasses or contact lenses annually if prescription changes

? Age 19 to 59 ? Replacement eyeglasses or contact lenses every two years if prescription changes

Replacement eyeglasses or contact lenses may be dispensed more frequently if significant vision changes occur.
Contact lens exams and fittings are covered only when deemed medically necessary over glasses.

DDD=Division of Developmental Disabilities FIDE-SNP=Horizon NJ TotalCare (HMO SNP) MLTSS=Managed Long Term Services & Supports



July 2019 | Member Services: 1-800-682-9090 (TTY 711) 4

What Horizon
NJ Health Covers BENEFIT PLAN TYPE
BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D

Optometrist Services Covered for one routine eye exam per year Covered for one routine eye exam per year with a $5 copayment

Organ Transplants Covered for transplant-related medical costs for the donor and recipient

Orthodontic Services
Coverage is limited to members up to age 21 or loss of eligbility who
require these services due to medical need, including developmental
problems or jaw injury. Prior authorization required.

Coverage is limited to members up to age 21 or
loss of eligibility who require these services due to
medical need, including developmental problems or
jaw injury, with a $5 copayment. Prior authorization
required.

Orthotics Covered

Outpatient Diagnostic Testing Covered

Partial Care Program Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Partial Hospital Program Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Personal Care Assistant Services Covered Not Covered

Personal Preference
Program Services Covered Not Covered

Podiatrist Services
Covered. Routine hygienic care of feet, including the treatment of corns
and calluses, trimming of nails and other hygienic care in the absence
of a pathological condition, is not covered.

Covered with a $5 copayment. Routine hygienic care
of feet, including the treatment of corns and calluses,
trimming of nails and other hygienic care in the
absence of a pathological condition, is not covered.

DDD=Division of Developmental Disabilities FIDE-SNP=Horizon NJ TotalCare (HMO SNP) MLTSS=Managed Long Term Services & Supports



July 2019 | Member Services: 1-800-682-9090 (TTY 711) 5

What Horizon
NJ Health Covers BENEFIT PLAN TYPE
BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D

Prescription Drugs
(Retail Pharmacy)

Covered, including atypical antipsychotics, buprenorphine/naloxone,
buprenorphine, naltrexone and methadone or any other drug within this
category when used for the treatment of opioid or alcohol dependence, and
drugs that may be excluded from Medicare Part D coverage. No coverage for
erectile dysfunction drugs and drugs not covered by a third-party Medicare
Part D formulary.

Covered with a $1 copayment for generic drugs and a
$5 copayment for brand-name drugs. Includes atypical
antipsychotics, buprenorphine/naloxone, buprenorphine,
naltrexone and methadone or any other drug within
this category when used for the treatment of opioid or
alcohol dependence, and drugs that may be excluded
from Medicare Part D coverage. No coverage for erectile
dysfunction drugs and drugs not covered by a third party
Medicare Part D formulary.

Prescription Drugs (Medicare
Part B Doctor-Administered) Covered

Primary Care, Specialty Care
and Women?s Health Services Covered

Covered with a $5 copayment for each visit. No
copayment for well-child visits, lead screening/
treatment, age-appropriate immunizations,
prenatal care or Pap tests.

Private Duty Nursing Covered for members under age 21, DDD Support Plus PDN and MLTSS members.

Prosthetics Covered

Radiology Services
(Diagnostic & Therapeutic) Covered

Rehabilitation Services
(Outpatient Physical Therapy,
Occupational Therapy and
Speech Therapy)

Covered

Sex Abuse Examinations
and Related Diagnostic Testing Covered by Fee-for-Service

Social Necessity Days Covered

Specialty Foods (Medical Foods) Coverage is limited to nutritional supplements requiring medical supervision for members with inborn errors of metabolism and related genetic conditions. Medical foods and special diets for all other medical conditions are not covered.

DDD=Division of Developmental Disabilities FIDE-SNP=Horizon NJ TotalCare (HMO SNP) MLTSS=Managed Long Term Services & Supports



July 2019 | Member Services: 1-800-682-9090 (TTY 711) 6

What Horizon
NJ Health Covers BENEFIT PLAN TYPE
BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D
Transportation Services ?
Emergency Ambulance (911) Coverage is limited to ambulance, ground and air, for medical emergencies only.

Transportation to Medically
Necessary Services Covered by Fee-for-Service through LogistiCare. To schedule, call LogistiCare at 1-866-527-9933 (TTY 1-866-288-3133).

Transportation ? Livery
Services (Bus and Train Fare or
Passes, Car Service, Mileage
Reimbursement) to Medically
Necessary Services

Covered by Fee-for-Service through LogistiCare.
To schedule, call LogistiCare at 1-866-527-9933
(TTY 1-866-288-3133).

Contact LogistiCare at 1-866-527-9933 (TTY 1-866-288-3133).

SUBSTANCE USE DISORDER SERVICES

Inpatient Medical Detox/
Medically Managed Inpatient
Withdrawal Management

Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Non-Medical Detoxification/
Non-Hospital Based Withdrawal
Management

Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Substance Use Disorder Short
Term Residential Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Residential Treatment Center
Services

Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.
? Prior authorization required; limited to members under 21 years of age

Ambulatory Withdrawal
Management with Extended
On-site Monitoring/
Ambulatory Detoxification

Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Substance Use Disorder
Partial Care Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

DDD=Division of Developmental Disabilities FIDE-SNP=Horizon NJ TotalCare (HMO SNP) MLTSS=Managed Long Term Services & Supports



July 2019 | Member Services: 1-800-682-9090 (TTY 711) 7

What Horizon
NJ Health Covers BENEFIT PLAN TYPE
BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D

SUBSTANCE USE DISORDER SERVICES (CONTINUED)
Substance Use Disorder Intensive
Outpatient Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Substance Use Disorder
Outpatient Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Opioid Treatment Services/
Methadone Office Based Addition
Treatment

Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Opioid Treatment Services/
Non-Methadone Office Based
Addition Treatment

Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

MENTAL HEALTH SERVICES

Psychiatric Emergency Services/
Affiliated Emergency Services Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Inpatient Psychiatric Services
(Acute Hospital Based) Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Inpatient Psychiatric Physician
Services (Acute Hospital Based) Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Psychiatric Hospital ? Inpatient
(Stand-alone) Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Partial Hospital Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.? Prior authorization required for acute Partial Hospitalization only
Adult Mental Health
Rehabilitation (Supervised Group
Homes and Apartments)

Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

DDD=Division of Developmental Disabilities FIDE-SNP=Horizon NJ TotalCare (HMO SNP) MLTSS=Managed Long Term Services & Supports



July 2019 | Member Services: 1-800-682-9090 (TTY 711)

What Horizon
NJ Health Covers BENEFIT PLAN TYPE
BENEFIT NJ FAMILYCARE A NJ FAMILYCARE ABP NJ FAMILYCARE B NJ FAMILYCARE C NJ FAMILYCARE D

MENTAL HEALTH SERVICES (CONTINUED)

Partial Care
(prior authorization required;
25 hours per week limit)

Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.
? Prior authorization required; 25 hours per week limit

Mental Health Outpatient
(Clinic/Hospital Services) Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Inpatient Practitioner or IPN
(Psychiatrist, Psychologist or APN) Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

Targeted Case Management
(Chronic Mental Illness) Covered for DDD, FIDE-SNP and MLTSS members. All other members are covered by Fee-for-Service.

8



July 2019 | Member Services: 1-800-682-9090 (TTY 711) 9

Services not covered by Horizon NJ Health or the
NJ FamilyCare Fee-for-Service program include:
? All services not medically necessary, provided, approved or

arranged by a Horizon NJ Health participating doctor (within
his or her scope of practice) except emergency services.

? Any service or items for which a provider does not normally
charge.

? Cosmetic services or surgery except when medically
necessary and approved.

? Experimental procedures or experimental organ transplants.

? Services provided by or in an institution run by the federal
government, such as the Veterans Administration hospitals.

? Respite care (except MLTSS members).

? Rest cures, personal comfort, convenience items and
services and supplies not directly related to the care of
the patient. Examples include guest meals and telephone
charges. Costs incurred by an accompanying parent(s) for an
out-of-state medical intervention are covered under EPSDT.

? Services in which health care records do not reflect the
requirements of the procedure described or procedure code
used by the provider.

? Services provided by an immediate relative or household
member.

? Services involving the use of equipment in facilities in which
its purchase, rental or construction has not been approved
by the State of New Jersey.

? Services resulting from any work-related condition or
accidental injury when benefits are available from any
workers? compensation law, temporary disability benefits
law, occupational disease law or similar law.

? Services provided or started while on active duty in the
military.

? Services or items reimbursed based on submission of a cost
study in which there is no evidence to support the costs
allegedly incurred or beneficiary income to make up for
those costs. If financial records are not available, a provider
may verify costs or available income using other evidence
that the NJ FamilyCare program accepts.

? Services provided outside the United States and its
territories.

? Infertility diagnoses and treatment services (including
sterilization reversals and related medical and clinic office
visits, drugs, laboratory services, radiological and diagnostic
services and surgical procedures).

? Services provided without charge. Programs offered free of
charge through public or voluntary agencies should be used
to the fullest extent possible.

? Any service covered under any other insurance policy or
other private or governmental health benefit system or
third-party liability.

Services not covered by NJ FamilyCare Fee-for-Service
or Horizon NJ Health



July 2019 | Member Services: 1-800-682-9090 (TTY 711) 10

Notice of Nondiscrimination

Horizon NJ Health complies with applicable Federal civil
rights laws and does not discriminate against nor does it
exclude people or treat them differently on the basis of race,
color, gender, national origin, age, disability, pregnancy,
gender identity, sex, sexual orientation or health status in the
administration of the plan, including enrollment and benefit
determinations.

Horizon NJ Health provides free aids and services to people
with disabilities to communicate effectively with us, such as
qualified sign language interpreters and information written
in other languages.

Contacting Member Services

Please call Member Services at 1-800-682-9090 (TTY 711)
or the phone number on the back of your member ID card,
if you need the free aids and services noted above and for
all other Member Services issues, including:

? Claim, benefits or enrollment inquiries
? Lost/stolen ID cards
? Address changes
? Any other inquiry related to your

benefits or health plan

Filing a Section 1557 Grievance

If you believe that Horizon NJ Health has failed to provide the
free communication aids and services or discriminated on the
basis of race, color, gender, national origin, age, or disability, you
can file a discrimination complaint also known as a Section 1557
Grievance. Horizon NJ Health?s Civil Rights Coordinator can be
reached by calling the Member Services number on the back of
your member ID card or by writing to the following address:

Horizon NJ Health ? Civil Rights Coordinator
PO Box 10194
Newark, NJ 07101

You can also file a civil rights complaint with the U.S. Department
of Health and Human Services, Office for Civil Rights,
electronically through the Office for Civil Rights Complaint Portal,
available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,
or by mail or phone at:

Office for Civil Rights Headquarters
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019 or 1-800-537-7697 (TTY)

OCR Complaint forms are available at
www.hhs.gov/ocr/office/file/index.html.

Para ayuda en espa?ol, llame a 1-800-682-9090 (TTY 711).



July 2019 | Member Services: 1-800-682-9090 (TTY 711) 11

Multi-language Interpreter Services

ATTENTION: If you speak a language other than English,
language assistance services, free of charge, are available to
you. Call 1-800-682-9090 (TTY 711). This document is also
available in other languages, as well as other formats, such
as large print and Braille.
ATENCION: Si habla espa?ol, tiene a su disposici?n servicios gratuitos de asistencia ling?istica. Llame al

1-800-682-9090 (TTY 711).

}'j?5t? 1-800-682-909051:? : ?D?f?f?JfFJifflcpx , 1?PJ.l:J%JU1H??R1fl'l.El}Jgfrf% 0 ?

??I: 21-?01? Ngo?AI? ??' 2101 J::1?! }dl::JI-"-? ?h? 01go??-* 5.:)?LIO.

1-800-682-9090 (TTY 711) \=:l::I O ? ? 2.? oH ? ? A I 2.

ATENCAO: Se fala portugues, encontram-se disponiveis serviyos linguisticos, gratis.

Ligue para 1-800-682-9090 (TTY 711).

? ?atl: ?l{l_ ct.it :>J?l$'?Lc-0 CiUC-tct.L ?, ctl ?:?c--s ?L"t:ll ?<?L2.l ?cu:uu ct.l{L?L l{L? GtLC-tei..\:.L ?- ?at 8?
1-800-682-9090 (TTY 711).

UWAGA: Jezeli m6wisz po polsku, mozesz skorzystac z bezplatnej pomocy j?zykowej. Zadzwori pod numer

1-800-682-9090 (TTY 711).

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti.

Chiamare il numero 1-800-682-9090 (TTY 711).

1-800-682-9090 ....,l.k...J\ wl4.i, , .... i.i.,;,. 0!-,o.lli..::..,..i..:.. 1.:i.s .J ?\.A ? .JI./ J....,:i _; ?o :O\) ,S.;..::.., _..,..lu,J? -1l.l _,1..g fa ?_,i.ll4..l:. y,,.: 1.1..

(711 /'Ur'""' _,l.l,,S)

PAUNA WA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad. Tumawag sa 1-800-682-9090 (TTY 711).

BHHMAHHE: Ecmr Bbl roBopttTe Ha pyccKOM 513bIKe, TO BaM ,D,OCTyntthI 6ecnnaTHhie ycnyrtt nepeBo,D,a.

3BOHIITe 1-800-682-9090 (TeJieTaiin 711).

ATANSYON: Si w pale Kreyol Ayisyen, gen sevis ed pou lang ki disponib gratis pou ou.

Rele 1-800-682-9090 (TTY 711).

t.? ?: ? 3-TfCT ? ? g-ill 3fr1cFl ? .:> ? al ? ti f, I <.l c1 I ? 3 q <>I ?tr g-1
1-800-682-9090 (TTY 711) ? cfiR>f cfiZI
CHU Y: NSu b.;in n6i TiSng Vi?t, c6 cac dich V\l h6 trq ngon ngfr mi?n phi danh cho b.;in. Goi s6
1-800-682-9090 (TTY 711).

ATTENTION: Si vous parlez franvais, des services d'aide linguistique vous sont proposes
gratuitement. Appelez le 1-800-682-9090 (ATS 711).

u-:...fi J\.S _ U:H y?..i U:/"' us.a wL.? ? ..l..l.a ? ,:J?j .fi Y.l ? 'Ll:H c11.J-! _,..i) Y.\ pl :)..i ?
1-800-682-9090 (TTY 711).

(TTY 711).



July 2019 | Member Services: 1-800-682-9090 (TTY 711) 12

Multi-language Interpreter Services

ATTENTION: If you speak a language other than English,
language assistance services, free of charge, are available to
you. Call 1-800-682-9090 (TTY 711). This document is also
available in other languages, as well as other formats, such
as large print and Braille.
ATENCION: Si habla espa?ol, tiene a su disposici?n servicios gratuitos de asistencia ling?istica. Llame al

1-800-682-9090 (TTY 711).

}'j?5t? 1-800-682-909051:? : ?D?f?f?JfFJifflcpx , 1?PJ.l:J%JU1H??R1fl'l.El}Jgfrf% 0 ?

??I: 21-?01? Ngo?AI? ??' 2101 J::1?! }dl::JI-"-? ?h? 01go??-* 5.:)?LIO.

1-800-682-9090 (TTY 711) \=:l::I O ? ? 2.? oH ? ? A I 2.

ATENCAO: Se fala portugues, encontram-se disponiveis serviyos linguisticos, gratis.

Ligue para 1-800-682-9090 (TTY 711).

? ?atl: ?l{l_ ct.it :>J?l$'?Lc-0 CiUC-tct.L ?, ctl ?:?c--s ?L"t:ll ?<?L2.l ?cu:uu ct.l{L?L l{L? GtLC-tei..\:.L ?- ?at 8?
1-800-682-9090 (TTY 711).

UWAGA: Jezeli m6wisz po polsku, mozesz skorzystac z bezplatnej pomocy j?zykowej. Zadzwori pod numer

1-800-682-9090 (TTY 711).

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti.

Chiamare il numero 1-800-682-9090 (TTY 711).

1-800-682-9090 ....,l.k...J\ wl4.i, , .... i.i.,;,. 0!-,o.lli..::..,..i..:.. 1.:i.s .J ?\.A ? .JI./ J....,:i _; ?o :O\) ,S.;..::.., _..,..lu,J? -1l.l _,1..g fa ?_,i.ll4..l:. y,,.: 1.1..

(711 /'Ur'""' _,l.l,,S)

PAUNA WA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad. Tumawag sa 1-800-682-9090 (TTY 711).

BHHMAHHE: Ecmr Bbl roBopttTe Ha pyccKOM 513bIKe, TO BaM ,D,OCTyntthI 6ecnnaTHhie ycnyrtt nepeBo,D,a.

3BOHIITe 1-800-682-9090 (TeJieTaiin 711).

ATANSYON: Si w pale Kreyol Ayisyen, gen sevis ed pou lang ki disponib gratis pou ou.

Rele 1-800-682-9090 (TTY 711).

t.? ?: ? 3-TfCT ? ? g-ill 3fr1cFl ? .:> ? al ? ti f, I <.l c1 I ? 3 q <>I ?tr g-1
1-800-682-9090 (TTY 711) ? cfiR>f cfiZI
CHU Y: NSu b.;in n6i TiSng Vi?t, c6 cac dich V\l h6 trq ngon ngfr mi?n phi danh cho b.;in. Goi s6
1-800-682-9090 (TTY 711).

ATTENTION: Si vous parlez franvais, des services d'aide linguistique vous sont proposes
gratuitement. Appelez le 1-800-682-9090 (ATS 711).

u-:...fi J\.S _ U:H y?..i U:/"' us.a wL.? ? ..l..l.a ? ,:J?j .fi Y.l ? 'Ll:H c11.J-! _,..i) Y.\ pl :)..i ?
1-800-682-9090 (TTY 711).

(TTY 711).



July 2019 | Member Services: 1-800-682-9090 (TTY 711) 13

Products are provided by Horizon NJ Health. Communications are issued by Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider
relations for all its companies. Both are independent licensees of the Blue Cross and Blue Shield Association.The Blue Cross? and Blue Shield? names and symbols are registered
marks of the Blue Cross and Blue Shield Association. The Horizon? name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey.
? 2019 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105. 086-19-71 EC003171 (0719)



July 2019 | Member Services: 1-844-444-4410 (TTY 711)

Effective April 1, 2019
As a member of Horizon NJ Health, you get the benefits and services you are entitled to in the Managed Long Term Services & Supports
(MLTSS) program. In addition to your NJ FamilyCare A or ABP benefits, other MLTSS services are available to you when assessed as a
need and identified in your Plan of Care.
If you are not sure whether a service is covered, call Member Services toll free at 1-844-444-4410 (TTY 711).

What Horizon NJ Health Covers
NJ FAMILYCARE BENEFIT DESCRIPTION

Abortions and Related Services Covered by NJ FamilyCare Fee-for-Service

Acupuncture Covered when provided by a licensed doctor

Adult Day Health/Medical Day Care Covered

Audiology Covered

Blood and Blood Plasma Covered

Chiropractic Services Coverage is limited to spinal manipulation

Cognitive Rehabilitation Therapy Covered

Comprehensive Dental Covered. Some services require prior authorization.

Dental Orthodontics
Coverage includes: limited interceptive and comprehensive based on demonstrated medical necessity. Age limits apply. All
services require prior authorization. Coverage is limited to members up to age 21 who require these services due to medical need,
including developmental problems or jaw injury. Prior authorization required.

DDD = Division of Developmental Disabilities FIDE-SNP = Horizon NJ TotalCare (HMO SNP) MLTSS = Managed Long Term Services & Supports

Member Benefits and Services

1



July 2019 | Member Services: 1-844-444-4410 (TTY 711) 2

What Horizon NJ Health Covers
NJ FAMILYCARE BENEFIT DESCRIPTION

Diabetic Supplies and Equipment Covered
Durable Medical Equipment
& Assistive Technology Devices Covered

Emergency Medical Care/
Emergency Services Covered

EPSDT (Early and Periodic
Screening, Diagnosis and Treatment)

Covered, including medical exams, dental, vision, hearing and lead screening
services. Covered for treatment services identified through the exam.

Family Planning Covered. Covered by Fee-for-Service when services are not given by a Horizon NJ Health doctor.

Group Homes and DCPP
Residential Treatment Facilities Covered

Hearing Aid Services Covered

Home Health Agency Services Covered, including nursing services by a registered nurse and/or licensed practical nurse; home health aide service; medical supplies and equipment; physical, occupational and speech therapy services; pharmaceutical services; and durable medical equipment.

Hospice Services Covered in the community as well as in institutional settings. Room and board are included only when services are delivered in an institutional (non-private residence) setting. Hospice care for children under age 21 shall cover both palliative and curative care.

Hospital Services (Inpatient) Covered

Hospital Services (Outpatient) Covered

Intermediate Care Facilities/
Intellectual Disability Covered by NJ FamilyCare Fee-for-Service

Laboratory Services Covered, including routine testing related to the administration of atypical antipsychotic drugs

Maternity Services Covered, including related newborn care and hearing screening

Medical Supplies Covered

DDD = Division of Developmental Disabilities FIDE-SNP = Horizon NJ TotalCare (HMO SNP) MLTSS = Managed Long Term Services & Supports



July 2019 | Member Services: 1-844-444-4410 (TTY 711) 3

What Horizon NJ Health Covers
NJ FAMILYCARE BENEFIT DESCRIPTION

Nurse Midwife Covered

Nurse Practitioner Covered

Nursing Facility Services
(Custodial Care, Rehabilitation,
Post-acute Care, Skilled Nursing
Care and Services in Special Care
Nursing Facilities, Such as Ventilator
Facilities, Pediatric Longterm Care
and Treatment for AIDS)

Covered

Opioid Treatment (Maintenance
and Administration) Covered

Optical Appliances

Covered for select eyeglasses and contact lenses as follows:

? Age 18 and under and 60 and older ? Replacement eyeglasses or contact lenses annually if prescription changes

? Age 19 to 59 ? Replacement eyeglasses or contact lenses every two years if prescription changes

Replacement eyeglasses or contact lenses may be dispensed more frequently if significant vision changes occur.
Contact lens exams and fittings are covered only when deemed medically necessary over glasses.

Optometrist Services Covered for one routine eye exam per year

Organ Transplants Covered for transplant-related medical costs for the donor and recipient, including donor and recipient costs.

Orthodontic Comprehensive Services Coverage is limited to members up to age 21 who require these services due to medical need, including developmental problems or jaw injury. Prior authorization required.
Orthotics Covered for children under 19 years old when medically necessary.

Outpatient Diagnostic Testing Covered

Partial Care Program Covered

Partial Hospital Program Covered

DDD = Division of Developmental Disabilities FIDE-SNP = Horizon NJ TotalCare (HMO SNP) MLTSS = Managed Long Term Services & Supports



July 2019 | Member Services: 1-844-444-4410 (TTY 711)
DDD = Division of Developmental Disabilities FIDE-SNP = Horizon NJ TotalCare (HMO SNP) MLTSS = Managed Long Term Services & Supports

4

What Horizon NJ Health Covers
NJ FAMILYCARE BENEFIT DESCRIPTION

Personal Care Assistant
(PCA Services) Covered

Personal Preference Program Services Covered

Podiatrist Services Covered. Routine hygienic care of feet, including the treatment of corns and calluses, trimming of nails and other hygienic care in the absence of a pathological condition, is not covered.

Prescription Drugs
(Retail Pharmacy)

Coverage includes:

? Atypical antipsychotics
? Buprenorphine/naloxone, buprenorphine, naltrexone and methadone or any other drug within this category when used for the

treatment of opioid dependence
? Drugs that may be excluded from Medicare Part D coverage

Coverage excludes:

? Erectile dysfunction drugs; and
? Drugs not covered by a third-party Medicare Part D formulary

Prescription Drugs ? Medicare
Part B (Doctor Administered) Covered

Primary Care, Specialty Care
and Women?s Health Services Covered

Private Duty Nursing Covered

Prosthetics Covered

Radiology Services
(Diagnostic & Therapeutic) Covered

Rehabilitation Services
(Outpatient Physical Therapy,
Cognitive Rehabilitation Therapy,
Occupational Therapy, and Speech
Pathology)

Covered



July 2019 | Member Services: 1-844-444-4410 (TTY 711) 5

What Horizon NJ Health Covers
NJ FAMILYCARE BENEFIT DESCRIPTION

Sex Abuse Examinations
and Related Diagnostic Testing Covered by NJ FamilyCare Fee-for-Service

Specialty Foods (Medical Foods) Coverage is limited to nutritional supplements requiring medical supervision for members with inborn errors of metabolism and related genetic conditions. Medical foods and special diets for all other medical conditions are not covered.

Transportation Services ?
Emergency Ambulance (911) Coverage is limited to medical emergencies only.

Transportation to Medically
Necessary Services

Covered by NJ FamilyCare Fee-for-Service through LogistiCare. To schedule, call LogistiCare (State transportation contractor).
NOTE: Members should call LogistiCare at 1-866-527-9933 (TTY 1-866-288-3133) to book a trip by 12 p.m. at least 48 hours
in advance of a routine transportation need.

SUBSTANCE USE DISORDER SERVICES

Inpatient Medical Detox/Medically
Managed Inpatient Withdrawal
Management

Covered

Non-Medical Detoxification/
Non-Hospital Based Withdrawal
Management

Covered

Substance Use Disorder Short Term
Residential Covered

Residential Treatment Center
Services

Covered
? Prior authorization required; limited to members under 21 years of age

Ambulatory Withdrawal
Management with Extended
On-site Monitoring/Ambulatory
Detoxification

Covered

Substance Use Disorder Partial Care Covered

DDD = Division of Developmental Disabilities FIDE-SNP = Horizon NJ TotalCare (HMO SNP) MLTSS = Managed Long Term Services & Supports



July 2019 | Member Services: 1-844-444-4410 (TTY 711)

What Horizon NJ Health Covers
NJ FAMILYCARE BENEFIT DESCRIPTION

SUBSTANCE USE DISORDER SERVICES (CONTINUED)

Substance Use Disorder Intensive
Outpatient Covered

Substance Use Disorder Outpatient Covered

Opioid Treatment Services/
Methadone Office Based
Addition Treatment

Covered

Opioid Treatment Services/
Non-Methadone Office Based
Addition Treatment

Covered

MENTAL HEALTH SERVICES

Psychiatric Emergency Services/
Affiliated Emergency Services Covered

Inpatient Psychiatric Services
(Acute Hospital Based) Covered

Inpatient Psychiatric Physician
Services (Acute Hospital Based) Covered

Psychiatric Hospital ? Inpatient
(Stand-alone) Covered

Partial Hospital Covered ? Prior authorization required for acute Partial Hospitalization only
Adult Mental Health Rehabilitation
(Supervised Group Homes and
Apartments)

Covered

DDD = Division of Developmental Disabilities FIDE-SNP = Horizon NJ TotalCare (HMO SNP) MLTSS = Managed Long Term Services & Supports
6



July 2019 | Member Services: 1-844-444-4410 (TTY 711)

What Horizon NJ Health Covers
NJ FAMILYCARE BENEFIT DESCRIPTION

MENTAL HEALTH SERVICES (CONTINUED)

Partial Care (prior authorization
required; 25 hours per week limit)

Covered
? Prior authorization required; 25 hours per week limit

Mental Health Outpatient (Clinic/
Hospital Services) Covered

Inpatient Practitioner or IPN
(Psychiatrist, Psychologist or APN) Covered

Targeted Case Management
(Chronic Mental Illness) Covered

7



July 2019 | Member Services: 1-844-444-4410 (TTY 711) 8

Additional Services
In addition to your NJ FamilyCare A or NJ FamilyCare ABP benefits, these MLTSS services may be available
to you when assessed as a need and identified in your Plan of Care.

MLTSS Benefit Description

Adult Family Care Living in the home or apartment of a trained caregiver who provides support and services to the member
Assisted Living Services A facility licensed by the Department of Health to provide apartment-style housing
Assisted Living Program Assisted living service to tenants of certain publicly subsidized senior housing buildings
Behavioral Management ?
Traumatic Brain Injury (TBI)
(Group and Individual)

Program provided in or out of the home designed to treat the member and caregivers when the member has a TBI diagnosis

Caregiver/Participant Training Training for caregivers

Chore Services Services needed to maintain the home in a clean and safe environment; not every day housekeeping tasks
Cognitive Therapy
(Group and Individual) Services to help support loss in function

Community Residential Services Services that help support and provide supervision for members with a TBI diagnosis

Community Transition Services Services provided to help move from an institutional setting into his/her own home in the community

Home-Based Supportive Care Services that assist with household needs (e.g., meal preparation, laundry)

Home-Delivered Meals Prepared meals brought to your home
Medication Dispensing Device A device to help give medications and medication reminders
Non-Medical Transportation Transportation to gain access to community services and activities
Nursing Facility Services (Custodial) Facility care with 24-hour medical supervision and continuous nursing care
Occupational Therapy
(Group and Individual) Services to help prevent loss of function



July 2019 | Member Services: 1-844-444-4410 (TTY 711) 9

MLTSS Benefit Description

Personal Emergency Response Systems A device that allows a member to call for help in an emergency

Physical Therapy (Group and Individual) Services to help prevent loss of function

Private Duty Nursing (Adult) Medically necessary nursing services

Residential Modifications Physical adaptations to a member?s private primary residence necessary to ensure health and safety (e.g., wheelchair ramp)

Respite (Daily and Hourly) A benefit to give caregivers a rest

Social Adult Day Care Community-based group program that provides health, social and related support services in a protective setting
Speech, Language and Hearing
Therapy (Group and Individual) Services to help prevent loss of function

Structured Day Program Structured day program to assist with the development, independence and community living skills of members
Supported Day Services Activities directed at the development of productive activity patterns for members
Vehicle Modifications Modifications to a member or family vehicle to allow greater independence



July 2019 | Member Services: 1-844-444-4410 (TTY 711) 10

Services not covered by Horizon NJ Health or the
NJ FamilyCare Fee-for-Service program include:

? All services not medically necessary, provided, approved or
arranged by a Horizon NJ Health participating doctor (within his
or her scope of practice) except emergency services.

? Any service covered under any other health insurance policy or
other private or governmental health benefit system or third-
party liability.

? Any service covered under any other insurance policy or other
private or governmental health benefit system or third-party
liability.

? Cosmetic services or surgery except when medically necessary
and approved.

? Experimental procedures or procedures not accepted as being
effective, including experimental organ transplants.

? Infertility diagnoses and treatment services (including sterilization
reversals and related medical and clinic office visits, drugs,
laboratory services, radiological and diagnostic services and
surgical procedures).

? Respite care for more than 30 days per year.

? Rest cures, personal comfort, convenience items and services
and supplies not directly related to the care of the patient.
Examples include guest meals and telephone charges.

? Services in which health care records do not reflect the
requirements of the procedure described or procedure code
used by the provider.

? Services involving the use of equipment in facilities in which its
purchase, rental or construction has not been approved by the
State of New Jersey.

? Services or items reimbursed based on submission of a cost
study in which there is no evidence to support the costs allegedly
incurred or beneficiary income to make up for those costs. If
financial records are not available, a provider may verify costs
or available income using other evidence that NJ FamilyCare
accepts.

? Services provided by an immediate relative or household
member, unless being delivered under the Self Directed Program.

? Services provided by or in an institution run by the federal
government, such as the Veterans Health Administration.

? Services provided or started while on active duty in the military.

? Services provided outside the United States and its territories.

? Services provided without charge. Programs offered free of
charge through public or voluntary agencies should be used to
the fullest extent possible.

? Services resulting from any work-related condition or
accidental injury when benefits are available from any
workers? compensation law, temporary disability benefits law,
occupational disease law or similar law.

Services not covered by NJ FamilyCare Fee-for-Service or
Horizon NJ Health



July 2019 | Member Services: 1-844-444-4410 (TTY 711)

Notice of Nondiscrimination

Horizon NJ Health complies with applicable Federal civil
rights laws and does not discriminate against nor does it
exclude people or treat them differently on the basis of race,
color, gender, national origin, age, disability, pregnancy,
gender identity, sex, sexual orientation or health status in the
administration of the plan, including enrollment and benefit
determinations.

Horizon NJ Health provides free aids and services to people
with disabilities to communicate effectively with us, such as
qualified sign language interpreters and information written
in other languages.

Contacting Member Services

Please call Member Services at 1-844-444-4410 (TTY 711)
or the phone number on the back of your member ID card,
if you need the free aids and services noted above and for
all other Member Services issues, including:

? Claim, benefits or enrollment inquiries
? Lost/stolen ID cards
? Address changes
? Any other inquiry related to your

benefits or health plan

Filing a Section 1557 Grievance

If you believe that Horizon NJ Health has failed to provide the
free communication aids and services or discriminated on the
basis of race, color, gender, national origin, age, or disability, you
can file a discrimination complaint also known as a Section 1557
Grievance. Horizon NJ Health?s Civil Rights Coordinator can be
reached by calling the Member Services number on the back of
your member ID card or by writing to the following address:

Horizon NJ Health ? Civil Rights Coordinator
PO Box 10194
Newark, NJ 07101
You can also file a civil rights complaint with the U.S. Department
of Health and Human Services, Office for Civil Rights,
electronically through the Office for Civil Rights Complaint Portal,
available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,
or by mail or phone at:

Office for Civil Rights Headquarters
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019 or 1-800-537-7697 (TTY)
OCR Complaint forms are available at
www.hhs.gov/ocr/office/file/index.html.
Para ayuda en espa?ol, llame a 1-844-444-4410 (TTY 711).

11



July 2019 | Member Services: 1-844-444-4410 (TTY 711)

Multi-language Interpreter Services

ATTENTION: If you speak a language other than English, language
assistance services, free of charge, are available to you. Call
1-844-444-4410 (TTY 711). This document is also available in other
languages, as well as other formats, such as large print and Braille.

ATENCI6N: si habla espafiol, tiene a su disposici6n servicios gratuitos de asistencia linguistica.

Llame al 1-844-444-4410 (TTY711).

;.1? : :t<o?f?ftm?m1crx: , f?PJ tJ:92,JtJtt?s!am:13.;IJij?? 0 8ll5Z? 1-844-444-4410
(TTY711 ).

??I: e._1-?o,? N?o?AI:= ?5F, '2:iO, ;::1? !dt:JIA? fp-5.? 01?0?? * v?uc?.
1-844-444-4410 (TTY711)? 0 ? ? .2loH ?? Al 2..

ATEN<;AO: Se fala portugues, encontram-se disponiveis servivos linguisticos, gratis. Ligue

para 1-844-444-4410 (TTY711).

??at.l: ?l?1. ct.it :>J<>i(?Lc-0. C>U.Hct.L ?' ctl R:?G-8 ?l"tll ??l? ?cu? ct.l-ll?l l-ll? G'Lt.Hu-\:.1. ?- $1.at.
8? 1-844-444-4410 (TTY711).

UWAGA: Jezeli m6wisz po polsku, mozesz skorzysta6 z bezplatnej pomocy j?zykowej.

Zadzwon pod numer 1-844-444-4410 (TTY711).

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza
linguistica gratuiti. Chiamare il numero 1-844-444-4410 (TTY 711).

?.J) 4410-444-844-1 ?Y. J....:.:ii .u?'-! ? .)lji:i ?y.111 r.?w1 -::.iL.? u? ,:i..i111 .fi?I ?? w.iS 1?J :?yJ..
.(711 ("?1_, ?I ?lA

P AUNA WA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong

sa wika nang walang bayad. Tumawag sa 1-844-444-4410 (TTY711).

BHHMAHHE: EcmI Bbl roB0p1ue Ha pyccKOM jl3bIKe, TO BaM ,r:i:ocTyrrHhI 6ecrrnaTHbie ycnynI
rrepeBo,r:i:a. 3BOHIITe 1-844-444-4410 (Tenerniirr 711).

ATANSYON: Si w pale Kreyol Ayisyen, gen sevis ed pou lang ki disponib gratis pou ou. Rele

1-844-444-4410 (TTY 711).

t.? ?: ? 3-TfCT ? ? e; ? 3fTqc), ?
.:>

? al ? ti f, I <.I ci I ? 3 q <>I <S:tf e; I
1-844-444-4410 (TTY 711) ? ? ? I

CHU Y: NSu b.;in n6i TiSng Vi?t, c6 cac dich V\l h6 trq ngon ngfr mi?n phi danh cho b.;in. Goi s6
1-844-444-4410 (TTY 711).

ATTENTION : Si vous parlez franvais, des services d'aide linguistique vous sont proposes
gratuitement. Appelez le 1-844-444-4410 (ATS 711).

u-:..fi J\.5. _ u::t y?..i ();/A us.a wL.? ? ..i..l.a ? u'-/j .fi Y.I _;i 'Lli:t c11 y, _,..i) Y.\ ).1 :)..i ?
1-844-444-4410 (TTY 711).

12



July 2019 | Member Services: 1-844-444-4410 (TTY 711)

Products and policies provided by Horizon NJ Health and services provided by Horizon Blue Cross Blue Shield of New Jersey, each an
independent licensee of the Blue Cross and Blue Shield Association. Communications may be issued by Horizon Blue Cross Blue Shield
of New Jersey in its capacity as administrator of programs and provider relations for all of its companies. ? 2019 Horizon Blue Cross
Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105. (0719) 086-19-71 EC003392

Multi-language Interpreter Services

ATTENTION: If you speak a language other than English, language
assistance services, free of charge, are available to you. Call
1-844-444-4410 (TTY 711). This document is also available in other
languages, as well as other formats, such as large print and Braille.

ATENCI6N: si habla espafiol, tiene a su disposici6n servicios gratuitos de asistencia linguistica.

Llame al 1-844-444-4410 (TTY711).

;.1? : :t<o?f?ftm?m1crx: , f?PJ tJ:92,JtJtt?s!am:13.;IJij?? 0 8ll5Z? 1-844-444-4410
(TTY711 ).

??I: e._1-?o,? N?o?AI:= ?5F, '2:iO, ;::1? !dt:JIA? fp-5.? 01?0?? * v?uc?.
1-844-444-4410 (TTY711)? 0 ? ? .2loH ?? Al 2..

ATEN<;AO: Se fala portugues, encontram-se disponiveis servivos linguisticos, gratis. Ligue

para 1-844-444-4410 (TTY711).

??at.l: ?l?1. ct.it :>J<>i(?Lc-0. C>U.Hct.L ?' ctl R:?G-8 ?l"tll ??l? ?cu? ct.l-ll?l l-ll? G'Lt.Hu-\:.1. ?- $1.at.
8? 1-844-444-4410 (TTY711).

UWAGA: Jezeli m6wisz po polsku, mozesz skorzysta6 z bezplatnej pomocy j?zykowej.

Zadzwon pod numer 1-844-444-4410 (TTY711).

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza
linguistica gratuiti. Chiamare il numero 1-844-444-4410 (TTY 711).

?.J) 4410-444-844-1 ?Y. J....:.:ii .u?'-! ? .)lji:i ?y.111 r.?w1 -::.iL.? u? ,:i..i111 .fi?I ?? w.iS 1?J :?yJ..
.(711 ("?1_, ?I ?lA

P AUNA WA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong

sa wika nang walang bayad. Tumawag sa 1-844-444-4410 (TTY711).

BHHMAHHE: EcmI Bbl roB0p1ue Ha pyccKOM jl3bIKe, TO BaM ,r:i:ocTyrrHhI 6ecrrnaTHbie ycnynI
rrepeBo,r:i:a. 3BOHIITe 1-844-444-4410 (Tenerniirr 711).

ATANSYON: Si w pale Kreyol Ayisyen, gen sevis ed pou lang ki disponib gratis pou ou. Rele

1-844-444-4410 (TTY 711).

t.? ?: ? 3-TfCT ? ? e; ? 3fTqc), ?
.:>

? al ? ti f, I <.I ci I ? 3 q <>I <S:tf e; I
1-844-444-4410 (TTY 711) ? ? ? I

CHU Y: NSu b.;in n6i TiSng Vi?t, c6 cac dich V\l h6 trq ngon ngfr mi?n phi danh cho b.;in. Goi s6
1-844-444-4410 (TTY 711).

ATTENTION : Si vous parlez franvais, des services d'aide linguistique vous sont proposes
gratuitement. Appelez le 1-844-444-4410 (ATS 711).

u-:..fi J\.5. _ u::t y?..i ();/A us.a wL.? ? ..i..l.a ? u'-/j .fi Y.I _;i 'Lli:t c11 y, _,..i) Y.\ ).1 :)..i ?
1-844-444-4410 (TTY 711).

13