January 1, 2018 December 31, 2018

Transcription

1 Dual-Eligible Special Needs Plan (DSNP) Guide Summary of Benefits January 1, 2018 December 31, 2018 Y0090_SNPSB_2018 Accepted

2 Horizon BCBSNJ 210 Silvia Street West Trenton, NJ HorizonBlue.com Notice of Nondiscrimination Horizon Blue Cross Blue Shield of New Jersey 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 BCBSNJ 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 (TTY/TDD 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 BCBSNJ 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 BCBSNJ 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 BCBSNJ Civil Rights Coordinator PO Box 820 Newark, NJ 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 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 or (TDD) OCR Complaint forms are available at Para ayuda en español, llame a (TTY/TDD 711). Independent licensees of the Blue Cross and Blue Shield Association* CMC F (0717) <2>

3 Multi-Language Insert Multi language Interpreter Services ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call (TTY/TDD 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY/TDD 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY/TDD 711). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY/TDD 711) 번으로전화해주십시오. ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY/TDD 711). ચન : જ તમ જર ત બ લત હ, ત ન: ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ લ છ. ફ ન કર (TTY/TDD 711). UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY/TDD 711). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY/TDD 711). ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم 711). <3>

4 PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY/TDD 711). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп 711). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY/TDD 711). य द : य द आप ह द ब लत ह त आपक लए म त म भ ष सह यत स व ए पल ह (TTY/TDD 711) पर क ल कर CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY/TDD 711). ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS 711). خبردار: اگر آپ اردو بولتے ہيں تو آپ کو زبان کی مدد کی خدمات مفت ميں دستياب ہيں کال کريں (TTY/TDD 711). Y0090_MultiLanguage4 Accepted <4>

5 SECTION I INTRODUCTION TO SUMMARY OF BENEFITS Thank you for your interest in Horizon NJ TotalCare (HMO SNP). Our plan is offered by HORIZON HEALTHCARE OF NEW JERSEY, INC., which is also called Horizon Blue Cross Blue Shield of New Jersey, Inc. a Medicare Advantage Health Maintenance Organization (HMO) Dual Special Needs Plan (D-SNP) that contracts with the Federal government and the New Jersey Medicaid program. This plan is designed for people who meet specific enrollment criteria. You are eligible to join this plan if you receive Medicare and full Medicaid benefits. Members will have $0 premium, $0 deductible, and $0 copay in this plan. Please call to find out if you are eligible to join. Our number is listed at the end of this introduction. This Summary of Benefits tells you some features of our plan. It doesn t list every service we cover or list every limitation or exclusion. To get a complete list of our benefits, please call and ask for the Evidence of Coverage. YOU HAVE CHOICES IN YOUR HEALTH CARE As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (feefor-service) Medicare Plan. Another option is a Medicare health plan, like. You may have other options, too. You make the choice. No matter what you decide, you are still in the Medicare Program. If you are eligible for both Medicare and Medicaid (dual eligible) you may join or leave a plan at any time. Please call at the number listed at the end of this introduction or MEDICARE ( ) for more information. TTY/TDD users should call You can call this number 24 hours a day, 7 days a week. WHERE IS HORIZON NJ TOTALCARE (HMO SNP) AVAILABLE? The service area for this plan includes: Atlantic, Cumberland, Essex, Gloucester, Hudson, Hunterdon, Mercer, Monmouth, Morris, Passaic, Salem, Somerset, Sussex, Union and Warren Counties, NJ. You must live in one of these areas to join the plan. WHO IS ELIGIBLE TO JOIN HORIZON NJ TOTALCARE (HMO SNP)? You can join if you are entitled to Medicare Part A, enrolled in Medicare Part B and live in the service area. However, individuals with End- Stage Renal Disease generally are not eligible to enroll in unless they are current members of a Horizon health plan and have been since their dialysis began. You must also be eligible for full Medicaid benefits to join this plan. Please call the plan to see if you are eligible to join. CAN I CHOOSE MY DOCTORS? has formed a network of doctors, specialists and hospitals. Except under certain circumstances, you can only use providers who are part of our network. The health providers in our network can change at any time. You can ask for a current provider directory. For an updated list, visit us at HorizonBlue.com/ doctorfinder. Our customer service number is listed at the end of this introduction. WHAT HAPPENS IF I GO TO A DOCTOR WHO S NOT IN YOUR NETWORK? has a network of doctors, hospitals, pharmacies, and other providers. If you use providers that are not in our network and were not referred there by your in-network provider, the plan may not pay for these services. WHERE CAN I GET MY PRESCRIPTIONS IF I JOIN THIS PLAN? has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. The pharmacies in our network can change at any time. You can ask for a pharmacy directory or visit us at Our customer service number is listed at the end of this introduction. <5>

6 SECTION I INTRODUCTION TO SUMMARY OF BENEFITS WHAT IF MY DOCTOR PRESCRIBES LESS THAN A MONTH S SUPPLY? In consultation with your doctor or pharmacist, you may receive less than a month s supply of certain drugs. Also, if you live in a long-term care facility, you will receive less than a month s supply of certain brand [and generic] drugs. Dispensing fewer drugs at a time can help reduce cost and waste in the Medicare Part D program, when this is medically appropriate. DOES MY PLAN COVER MEDICARE PART B OR PART D DRUGS? covers both Medicare Part B prescription drugs and Medicare Part D prescription drugs. WHAT IS A PRESCRIPTION DRUG FORMULARY? uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove or make changes to coverage limitations on certain drugs. If we make any formulary change that limits our members ability to fill their prescriptions, we will notify the affected members before the change is made. We will send a formulary to you and you can see our complete formulary on our website at If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician s help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy. WHAT ARE MY PROTECTIONS IN THIS PLAN? All Medicare Advantage Plans agree to stay in the program for a full calendar year at a time. Plan benefits may change from calendar year to calendar year. Each year, plans can decide whether to continue to participate with Medicare Advantage. A plan may continue in their entire service area (geographic area where the plan accepts members) or choose to continue only in certain areas. Also, Medicare may decide to end a contract with a plan. Even if your Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue for an additional calendar year, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area. As a member of, you have the right to request an organization determination, which includes the right to file an appeal if we deny coverage for an item or service, and the right to file a grievance. You have the right to request an organization determination if you want us to provide or pay for an item or service that you believe should be covered. If we deny coverage for your requested item or service, you have the right to appeal and ask us to review our decision. You may ask us for an expedited (fast) coverage determination or appeal if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision. Finally, you have the right to file a grievance with us if you have any type of problem with us or one of our network providers that does not involve coverage for an item or service. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information. As a member of, you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D <6>

7 SECTION I INTRODUCTION TO SUMMARY OF BENEFITS drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs. You can also ask for an exception to utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information. WHAT IS A MEDICATION THERAPY MANAGEMENT (MTM) PROGRAM? A Medication Therapy Management (MTM) Program is a free service we offer for members who meet certain eligibility requirements. The aim of the MTM program is to work with you and your doctor to help you achieve and maintain the safest and most effective medication therapy for you. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Contact for more details. WHERE CAN I FIND INFORMATION ON PLAN RATINGS? The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). If you have access to the web, you may use the web tools on and select Health and Drug Plans then Compare Drug and Health Plans to compare the plan ratings for Medicare plans in your area. You can also call us directly to obtain a copy of the plan ratings for this plan. Our customer service number is listed below. For more information about, call toll free at: (TTY/TDD 711) Customer Service Hours of Operation are 24 hours a day, 7 days a week. Or you can visit us at Medicare.HorizonBlue.com For more information about Medicare, please call Medicare at MEDICARE ( ). TTY users should call You can call 24 hours a day, 7 days a week. Or, visit on the web. <7>

8 SECTION I INTRODUCTION TO SUMMARY OF BENEFITS This document is available in large print and Spanish. This document is available in other non-english languages. For additional information, call customer service at the phone number listed above. Esta información puede estar disponible en un formato distinto, incluido el idioma español, letra grande. Llame al Departamento de Servicios al Miembro al número indicado arriba si necesita información sobre el Plan en otro formato o idioma. If you have any questions about the plan s benefits, please call toll free at (TTY/TDD 711). Customer Service Hours of Operation are 24 hours a day, 7 days a week. <8>

9 Section II Summary of Benefits Benefit IMPORTANT INFORMATION 1 How much is the monthly premium? $0 monthly plan premium. 2 How much is the deductible? $0 annual deductible. 3 Is there a maximum out-of-pocket responsibility for my covered services? (Does not include prescription drugs) $0, you will have no cost-sharing responsibility for services. COVERED MEDICAL AND HOSPITAL BENEFITS 4 Inpatient Hospital Care (includes Substance Abuse and Rehabilitation Services) Our plan covers an unlimited number of days for an inpatient hospital stay. It covers stays in critical access hospitals; inpatient rehabilitation facilities; inpatient mental health care; semi-private room accommodations; physicians and surgeons services; anesthesia; lab, x-ray, and other diagnostic services; drugs and medication; therapeutic services; general nursing; and other services and supplies that are usually provided by the hospital. $0 deductible for each hospital stay. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. <9>

10 5 Outpatient Hospital Care We cover medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. Covered services include, but are not limited to: Services in an emergency department or outpatient clinic, such as observation services or outpatient surgery Laboratory and diagnostic tests billed by the hospital Mental health care, including care in a partial-hospitalization program, if a doctor certifies that inpatient treatment would be required without it X-rays and other radiology services billed by the hospital Medical supplies such as splints and casts Certain drugs and biologicals that you can t give yourself for each outpatient hospital facility visit 6 Doctor Office Visits for each primary care doctor visit. for each specialist visit. <10>

11 7 Preventive Services for annual physical exams for all preventive services The following preventive care screenings are covered: Alcohol Abuse-Screening and behavioral Counseling Interventions in Primary Care to Reduce Alcohol Abuse. Abdominal Aortic Aneurysm Screening Bone Mass Measurement Screening Cardiovascular Disease Testing (Lab) Cardiovascular Disease Intensive Behavioral Therapy (IBT) Colorectal Screening Depression Screening Diabetes Screening Test (Lab) Diabetic Supplies/Services & Diabetes Self Management training Glaucoma Screening Only Hepatitis C Screening HIV Screening Immunizations (Pneumonia Vaccine / Flu shots / Hep B Vaccine /Other vaccines) Initial Preventive Physical Exam (IPPE) Lung Cancer Screening Counseling and Annual Screening for Lung Cancer with Low Dose Computed Tomography Mammography (Annual) Medical Nutrition Therapy Obesity-Intensive Behavioral Therapy (IBT) for Obesity Pap Test / Pelvic Exam Prostate Cancer Screening Sexually Transmitted Infections (STIs) Screening & High Intensity Behavioral Counseling (HIBC) to Prevent STIs Any additional preventive services approved by Medicare mid-year will be covered by the plan. <11>

12 8 Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care) Covered, including coverage for services rendered beyond Medicare Part A & B limits. $0 deductible for emergency room visits Coverage is limited to $60,000 worldwide when you are temporarily outside of the United States and its territories. 9 Urgently Needed Care (This is NOT emergency care, and in most cases, is out of the service area) for urgently-needed-care visits. Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services may be furnished by network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible. Coverage is limited to $60,000 worldwide when you are temporarily outside of the United States and its territories. 10 Diagnostic Tests, X-rays, Lab Services and Radiology Services for: lab services diagnostic procedures and tests X-rays diagnostic radiology services (not including X-rays) therapeutic radiology services <12>

13 11 Hearing Services The plan covers: Routine hearing exams, diagnostic hearing exams and balance exams, otologic and hearing aid examinations prior to prescribing hearing aids Exams for the purpose of fitting hearing aids, follow-up exams and adjustments, and repairs after warranty expiration Hearing aids, as well as associated accessories and supplies, are covered Covered for services rendered beyond Medicare Part B limits. $0 deductible 12 Dental Services Covered care includes (but is not limited to): Diagnostics (X-rays and exams) Preventive (cleanings and fluoride treatments) Restorative (crowns, silver or tooth-colored fillings) Endodontics (root canals) Periodontal (gum treatments/ therapies) Prosthetics (dentures and fixed bridges) Oral and maxillofacial surgical (extractions) Adjunctive services $0 deductible for dental benefits for dental benefits <13>

14 13 Vision Services Covers medically necessary eye care services for: Detection and treatment of disease and injury to the eye Annual diabetic retinal exam Glaucoma screening Macular degeneration screening Covered for services rendered beyond Medicare Part B benefit limits such as: Routine eye examination Optometrist services and optical appliances, including artificial eyes, low vision devices, vision training devices, and intraocular lenses, are covered. Replacement lenses and frames (or contact lenses) are covered --Once every 24 months for beneficiaries age 19 through 59 --Once per year for those 18 years of age or younger and those 60 years of age or older Optometrist services and optical appliances must be obtained at a participating Davis Vision Provider. $0 deductible <14>

15 14 Mental Health Services Inpatient Mental Health Care The plan covers up to 190 days of inpatient services in a psychiatric hospital. Services beyond 190 days will be covered directly by Medicaid Fee-for-Service. All members are covered by the plan for acute inpatient hospitalization in a general hospital, regardless of the admitting diagnosis or treatment. Mental health services are covered by the plan for all members beyond 190 days by the Medicaid portion of the plan s coverage. Services in a general hospital, psychiatric unit of an acute care hospital, Short Term Care Facility (STCF), or critical access hospital are covered. The Medicaid portion of the plan s coverage includes inpatient substance use disorder treatment services. Detoxification in a medical acute care inpatient setting is covered by the plan for all members. Short Term Residential Substance Use Disorder treatment is covered for all members. It covers up to 14 days of treatment in a facility licensed to provide residential alcohol and substance use disorder services. Psychiatric Acute Partial Hospitalization is covered by the plan. Admission is only through a psychiatric emergency screening center or post psychiatric inpatient discharge. $0 deductible Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. Outpatient Mental Health Care Covers: Outpatient psychiatric services in general hospitals and private psychiatric hospitals for patients of all ages Services in hospital based and community based settings Screening, prescription drugs, and for treatment of conditions $0 deductible <15>

16 15 Skilled Nursing Facility (SNF) (in a Medicarecertified skilled nursing facility) Covers Nursing Facility services and Nursing Facility. Long Term/Custodial Care coverage is unlimited if medically necessary. $0 deductible for SNF services 16 Physical Therapy Medically necessary physical therapy is covered. 17 Outpatient Rehabilitation Services Cardiac and Pulmonary Rehabilitation Services for: Cardiac Rehabilitation Services Intensive Cardiac Rehabilitation Services Pulmonary Rehabilitation Services Occupational Therapy, Speech and Language Therapy Rehabilitation Services Medically necessary occupational therapy and speech and language pathology services are covered. for Occupational Therapy visits for Speech and Language Pathology visits 18 Ambulance Services (medically necessary ambulance services) for ambulance benefits. <16>

17 19 Transportation (Emergent) (Ambulance, Mobile Intensive Care Unit) Covered for services rendered beyond Medicare Part B benefit limits. Medically necessary ground ambulance transportation to a hospital or skilled nursing facility for medically necessary services. May cover emergency ambulance transportation in an airplane or helicopter if ground transportation cannot provide the immediate and rapid transportation that is necessary. 20 Blood and Blood Products Whole blood and derivatives, as well as necessary processing and administration costs, are covered. Coverage begins with the first pint of blood. Coverage is unlimited (no limit on volume or number of blood products). 21 Early Periodic Screening and Diagnostic Treatment (EPSDT) Coverage includes (but is not limited to) well child care, preventive screenings, medical examinations, vision and hearing screenings and services,immunizations, lead screening, and private duty nursing services. Private duty nursing is covered for eligible EPSDT beneficiaries under 21 years of age who live in the community and whose medical condition and treatment plan justify the needs. 22 Family Planning Services and Supplies Covered services include medical history and physical examination (including pelvis and breast), diagnostic and laboratory tests, drugs and biologicals, medical supplies and devices (including pregnancy test kits, condoms, diaphragms, Depo-Provera injections, and other contraceptive supplies and devices), counseling, continuing medical supervision, continuity of care and genetic counseling. Services furnished by out-of-network providers are covered directly by Medicaid feefor-service. 23 Federally Qualified Health Centers (FQHC) Includes outpatient and primary care services from community-based organizations. <17>

18 24 Foot Care (podiatry services) for podiatry visits. Covers routine exams and medically necessary podiatric services, as well as therapeutic shoes or inserts for those with severe diabetic foot disease, and exams to fit those shoes or inserts. 25 Health/Wellness Education, including preventive healthcare and counseling, health promotion Coverage includes (but is not limited to) medical nutrition therapy for members with diabetes or kidney disease, diabetes education, tobacco use cessation counseling, alcohol misuse counseling, and depression. 26 Managed Long Term Services and Supports (MLTSS) MLTSS includes services for members who need the level of care typically provided in a nursing facility, and provides the support needed to allow them to receive the care they need in their home or community as long as possible. Covered for those who meet the associated financial and clinical eligibility requirements. Ask your Care Manager for more information. 27 Medical Day Care Provides preventive, diagnostic, therapeutic and rehabilitative services under medical and nursing supervision in an ambulatory care setting to meet the needs of individuals with physical and/or cognitive impairments in order to support their community living. <18>

19 28 Medical Equipment/ Supplies Covered for services rendered beyond Medicare Part B limits for approved procedures and services. Some items include wound care, suction, tape, gloves, and wound dressing, specialty medical foods, assistive technology devices, incontinence supplies and wigs for certain medical conditions. Durable Medical Equipment (includes wheelchairs, oxygen, etc.) $0 deductible for durable medical equipment Prosthetic Devices (includes braces, artificial limbs and eyes, etc.) for: prosthetic devices medical supplies related to prosthetics, splints, and other devices Diabetes Programs and Supplies for Diabetes self-management training for: Diabetes monitoring supplies Therapeutic shoes or inserts 29 Medicare Part B Drugs $0 yearly deductible for Medicare Part B drugs. for Part B chemotherapy drugs and other Part B drugs. Examples of Part B drugs include some antigens prepared by a doctor and administered by a properly instructed person, injectable osteoporosis drugs, erythropoietin by injection if you have end stage renal disease and need this drug to treat anemia, hemophilia clotting factors, some oral cancer drugs, and inhalation and infusion drugs administered through Durable Medical Equipment. 30 Acupuncture Coverage limited to acupuncture provided by a licensed physician (MD or DO). <19>

20 31 Nurse Midwife Services Covered 32 Organ Transplants Covers medically necessary organ transplants including, liver, lung, heart, heart-lung, pancreas, kidney, liver, cornea, intestine, and bone marrow transplants (including autologous bone marrow transplants). Includes donor and recipients costs. 33 Personal Care Assistance Covers health related tasks performed by a qualified individual in a member s home, under the supervision of a registered professional nurse, as certified by a physician in accordance with a member s written plan of care. Services limited to 40 hours per week. The plan may approve more than 40 hours per week for members with MLTSS. 34 Private Duty Nursing Private duty nursing is covered for members under 21 years of age who live in the community and whose medical condition and treatment plan justify the need. Available to MLTSS members of any age. <20>

21 35 Chiropractic Services for chiropractic visits Covers manipulation of the spine, as well as certain services, such as clinical laboratory services; certain medical supplies; durable medical equipment; prefabricated orthoses; physical therapy services; and diagnostic radiological services when they are prescribed by a chiropractor within their scope of practice. 36 Home Health Care (includes medically necessary intermittent skilled nursing care, home health aide services and rehabilitation services, etc.) Coverage includes nursing services by a registered nurse and/or licensed practical nurse; home health aide service; medical supplies and equipment, and appliances suitable for use in the home; audiology services; physical therapy; speech-language pathology; and occupational therapy. for home health visits 37 Hospice You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice. Please contact us for more details and we can guide you. Covers drugs for pain relief and symptoms management; medical, nursing, and social services; and certain durable medical equipment and other services, including spiritual and grief counseling. Covered in the community as well as in institutional settings. Room and board are not covered in a member s home, or in a facility (such as a nursing home) that serves as the member s normal residence. Hospice care for enrollees under 21 years of age shall cover both palliative and curative care. Covered for services rendered beyond Medicare Parts A & B limits. <21>

22 38 Outpatient Substance Abuse Care Methadone cost, administration, and maintenance covered by the plan for all members. for: each individual substance abuse outpatient treatment visit each group substance abuse outpatient treatment visit 39 Outpatient Services for each ambulatory surgical center visit for each outpatient hospital facility visit 40 OTC (Over-the- Counter) Catalog The OTC Catalog is part of your health plan. Every three (3) months you will receive a $125 credit that will allow you to purchase personal health items without a prescription from our OTC catalog. Examples of these personal health items are first aid kit, folding cane, denture cream, and more. The quarterly credit will not carry over from quarter to quarter or from year to year. All orders must be placed using the plan s approved vendor and all orders will be delivered through mail. Orders can be placed through the phone at and start 1/1/2018 online at HorizonBlueOTC.com. 41 Renal Dialysis for renal dialysis for kidney disease education services. 42 Routine Podiatry Care 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 covered. We allow up to eight (8) visits per year. <22>

23 43 Transportation (Routine Non- Emergent) Routine non-emergent medical transportation is covered directly by Medicaid Feefor-Service and must be arranged through LogistiCare (the State Transportation Contractor). The member s Primary Care Physician or other provider may assist in arranging this transportation, and the member may also seek help from their Care Manager. Please call to contact LogistiCare. 44 Medicare Part B Drugs $0 yearly deductible for Medicare Part B drugs. for Part B chemotherapy drugs and other Part B drugs. Examples of Part B drugs include some antigens prepared by a doctor and administered by a properly instructed person, injectable osteoporosis drugs, erythropoietin by injection if you have end stage renal disease and need this drug to treat anemia, hemophilia clotting factors, some oral cancer drugs, and inhalation and infusion drugs administered through Durable Medical Equipment /7 Nurse Line Enables you to speak with a registered nurse, toll free 24 hours a day to assist with health-related questions and concerns. Please call to contact the 24/7 Nurse Line 46 Worldwide Emergency/Urgent Care Coverage is limited to $60,000 worldwide when you are temporarily outside of the United States and its territories. <23>

24 PRESCRIPTION DRUG BENEFITS 48 Outpatient Prescription Drugs Drugs Covered under Medicare Part D This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will continue to have no cost sharing amount for your prescription drugs if you get them at an in network pharmacy outside of the plan s service area (for instance when you travel). The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from Horizon NJ TotalCare (HMO SNP) for certain drugs. Drugs covered by Medicaid Includes prescription drugs (legend and non-legend covered by the Medicaid program including physician administered drugs); prescription vitamins and mineral products (except prenatal vitamins and fluoride), including, but not limited to, therapeutic vitamins, such as high potency A, D, E, Iron, Zinc, and minerals including potassium, and niacin. Horizon will continue to cover physician administered drugs for all enrollees. Covered for services rendered beyond Medicare Part B and Part D benefit limits. You must have a provider (a doctor or other prescriber) write your prescription. You can refer to the Medicaid Wrap Drug Coverage List posted on horizonblue.com/prescription-drug-list-formulary-medicaid-wrap-drug-list for a comprehensive listing of covered drugs. You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan s website, formulary and printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. You pay a $0 annual deductible. You pay the following: For generic drugs (including brand drugs treated as generic): For all other drugs: (Continued on next page) <24>

25 49 Outpatient Prescription Drugs (continued) Retail Pharmacy Contact your plan if you have questions when less than a one-month supply is dispensed. You can get drugs the following way(s): one-month (30-day) supply two-month (60-day) supply three-month (90-day) supply Long-Term Care Pharmacy Long term care pharmacies must dispense certain oral brand name drugs in amounts less than a 14 day supply. They may also dispense less than a month s supply of generic drugs at a time. Contact your plan if you have questions when less than a one month supply is dispensed. You can get drugs the following way(s): one-month (31-day) supply of drugs Mail Order Contact your plan if you have questions when less than a one-month supply is dispensed. You can get drugs the following way(s): one-month (30-day) supply two-month (60-day) supply three-month (90-day) supply Out-of-Network Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan s service area where there is no network pharmacy. You can get out-of-network drugs the following way: one-month (30-day) supply <25>

26 ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call (TTY/TDD 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY/TDD 711). This information is not a complete description of benefits. Contact the plan for more information. Limitations and restrictions may apply. Benefits may change on January 1 of each year. Medicaid will cover in full your Part B premium. The Formulary, pharmacy network and provider network may change at any time. You will receive notice when necessary. This plan is available to anyone who has both Medicare and full Medicaid benefits. Members must use a SNP network provider. Members must use a SNP network DME (Durable Medical Equipment) supplier. Members must use a SNP network pharmacy. Members will be enrolled into Part D coverage under the SNP and will be automatically disenrolled from any other Medicare Part D or creditable coverage plan in which they are currently enrolled. has been approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) until 12/31/2018 based on a review of s Model of Care. Horizon Healthcare of New Jersey, Inc. ( HHNJ ) has contracts with both CMS and the State of New Jersey Medicaid Program to provide a HMO Medicare Advantage Dual Special Needs plan. Enrollment in depends on contract renewal. Products are provided by HHNJ, however, 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 companies 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 Horizon Blue Cross Blue Shield of New Jersey, Three Penn Plaza East, Newark, New Jersey