Important - Please Read

By proceeding to access this Medical Policy Manual, you acknowledge receipt of and agreement with the following:

The purpose of the Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) Medical Policy Manual is to provide information relating to the administration of plan benefits in relation to the insured’s contract. It is applicable to the administration of health benefits that Horizon BCBSNJ insures or administers.

If the insured’s contract benefits differ from the medical policy, the contract prevails. Applicable Federal and/or State regulations must be considered in the determinations. Coverage determinations are made on a case-by-case basis. Although a procedure or technology may be medically necessary, it may be excluded in a member’s benefit plan. If a service/supply is not eligible for coverage, a member and the treating provider are still free to proceed with that service/supply knowing plan benefits are not available.

Horizon BCBSNJ coverage determinations are benefit decisions only, and are not the provision of medical care. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. Only the treating provider can render medical care, and only the treating provider is responsible for the quality or appropriateness of the medical care provided, or the skill with which it is provided.

Medical Policies can be highly technical and are designed for use by our professional staff in making coverage determinations. Members/Covered Persons 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.

Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract, or guarantee of payment.

The Medical Policies are specifically written to address the clinical circumstances of the majority of people. However, an individual’s unique clinical circumstances will be considered in light of these policies and peer-reviewed, evidence-based scientific literature.

The Horizon BCBSNJ Medical Policy Manual is confidential and proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy Manual are not to be copied, reproduced, or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy Manual may be updated or changed without notice. However, benefit determinations are made in the context of Medical Policies existing at the time of the decision, and are not subject to later revision as the result of a change in Medical Policy.

Horizon Blue Cross Blue Shield of New Jersey may also has a pharmacy drug policy guideline [and/or Horizon NJ Health policy]. Policy criteria may vary by line of business. Please consult the appropriate policy applicable to your patient’s circumstances; pharmacy policies are available as noted below:

The Horizon Blue Cross Blue Shield 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

Horizon NJ Health policies (Medicaid) are available athttps://services3.horizon-bcbsnj.com/ddn/NJhealthWeb.nsf