If the benefits available to a member pursuant to the member’s benefit plan differ from what is stated in a medical policy, the benefit plan prevails.

Although a service, supply, or procedure may be medically necessary, it nevertheless may be subject to limitations and/or exclusions under a member’s benefit plan.

If a service, treatment, procedure, equipment, device, supply, or drug is not covered, and if the member nevertheless proceeds to obtain any of them, the member may be responsible for the cost to the extent permitted under the member’s benefit plan and applicable law. For information about their benefits and payment of those benefits, the member should consult their plan document.

The policies in this database are not intended to direct the course of clinical care, and they do not replace a physician’s or other health care professional’s independent clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Decisions regarding treatment and treatment plans are the responsibility of physicians and other health care professionals. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. Physicians and other health care professionals remain responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.

Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract, or a guarantee of payment. Payment is determined based on all terms, conditions, limitations, and exclusions of the member’s benefit plan, including the medical necessity of the services provided; the member’s eligibility at the time the services are provided; the agreement between the physician or other health care professional and Horizon BCBSNJ, if applicable; and the out-of-network fee schedule for the member’s benefit plan, if applicable.

The medical policies are written taking into consideration information from such sources as applicable Federal and State regulations, evidence-based scientific literature, standards of practice, and opinions of community physicians and professional societies. Although the medical policies are specifically written to address the clinical circumstances of the majority of people, Horizon BCBSNJ will consider an individual’s unique clinical circumstances, as well as the sources noted in the respective medical policies, when making these decisions on a case-by-case basis.

Medical policies are highly technical and are designed for use by Horizon BCBSNJ professional staff in making coverage determinations and by physicians and other health care professionals in understanding those decisions. Members who are provided with a copy of a medical policy should discuss the medical policy with their treating provider and should refer to their specific benefit plan for the terms, conditions, limitations, and exclusions of their coverage.

The Horizon BCBSNJ Medical Policy Manual is proprietary. Horizon BCBSNJ reserves the right to update or change the contents of this Medical Policy Manual without notice, as the law allows. Horizon BCBSNJ makes benefit determinations based on the medical policies in existence at the time Horizon BCBSNJ receives a request (e.g., prior authorization or prior determination) or based on the actual date of service on a claim for the service, treatment, procedure, equipment, device, supply, or drug. Horizon BCBSNJ will not later revise its benefit determinations as the result of any subsequent updates or changes in medical policy.

Horizon BCBSNJ has various categories of medical policies. Policy criteria may also vary by line of business, and notes in the respective policies will indicate the specific guidance. In addition, it should be noted that, in addition to this Medical Policy Manual, Horizon BCBSNJ’s delegated vendors also maintain libraries of medical policies that have been reviewed and adopted by Horizon BCBSNJ.

The Horizon Blue Cross Blue Shield of New Jersey pharmacy policy guidelines are available at

https://www.myprime.com/v/HBCBSNJ/COMMERCIAL/NJCLASSIC/en/forms/coverage-determination/prior-authorization.html for Classic formulary;

https://www.myprime.com/v/HBCBSNJ/COMMERCIAL/NJIADVANT/en/forms/coverage-determination/prior-authorization.html for Classic with Health Insurance Marketplace formulary;
https://www.myprime.com/content/dam/prime/memberportal/forms/2019/FullyQualified/Other/ALL/HBCBSNJ/MEDICARE_D/NJMBNGCPPO/Prior_Authorization_Criteria.pdf for Medicare Part D formulary
https://www.myprime.com/content/dam/prime/memberportal/forms/2019/FullyQualified/Other/ALL/HBCBSNJ/MEDICARE_D/NJSNPHMO/Prior_Authorization_Criteria.pdf for Medicare DSNP formulary

For Horizon NJ Health members, please follow this link for the corresponding HNJH drug policy https://services3.horizon-bcbsnj.com/ddn/NJhealthWeb.nsf