Plan Document Request

Evidence of Coverage, Formulary, Provider or Pharmacy Directory

Now, you have three simple ways to get information about your Horizon Medicare plan.
Call 1-888-425-9431 (TTY/TDD #: 711) Monday to Sunday, 8 a.m. to 8 p.m., Eastern Time
Visit http://HorizonBlue.com/Medicare
Request these documents for free using the simple request form below.

HORIZON MEDICARE DOCUMENT REQUEST FORM

First Name
Last Name
Address 1
Address 2
City
State
Zip
Email
County
Fields marked with an asterisk (*) are required.

Please send me the following item(s):

Select Plan








Horizon Insurance Company (“HIC”) contracts with CMS to offer HMO, HMO-POS, PPO and Part D Medicare plans. Horizon NJ TotalCare (HMO SNP) is an HMO Medicare Advantage Dual Special Needs plan with a Medicare contract and a contract with the State of New Jersey Medicaid Program. Enrollment in HIC Medicare products and Horizon NJ TotalCare (HMO SNP) depends on contract renewal. Products are provided by HIC, HHNJ and Horizon Blue Cross Blue Shield of New Jersey, all of which are independent licensees of the Blue Cross and Blue Shield Association. 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. 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. © 2018 Horizon Blue Cross Blue Shield of New Jersey, Three Penn Plaza East, Newark, New Jersey 07105.

Horizon Blue Cross Blue Shield of New Jersey 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 (Español): Para ayuda en español, llame al 1-800-365-2223 (TTY/TDD 711).

Chinese (中文):如需中文協助❜請致電 1-800-365-2223 (TTY/TDD 711) °

© 2019 Horizon Blue Cross Blue Shield of New Jersey, Three Penn Plaza East, Newark, New Jersey 07105

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Last updated: 09/19/2018