As a member of Horizon NJ Health, you get the
benets you are entitled to through the
NJ FamilyCare program.
Members with MLTSS benets do not have
copayments for covered services. MLTSS members
do have a cost share, or Patient Payment Liability
for Assisted Living and Nursing Facilities.
Make sure you know how Horizon NJ Health
works, especially when it comes to emergency
care, seeing your doctor and when you need a
referral. Otherwise, you might be billed if you
get services that are not covered by Horizon
NJ Health or authorized by your PCP. Before care
is given, your doctor should tell you if a service
is not covered and if you will be billed for the
service.
If you are not sure whether a service is covered,
call Member Services toll free at 1-844-444-4410
(TTY 711).
Your Benets
You have access to NJ FamilyCare benets
What Horizon NJ Health Covers
NJ FamilyCare Benet 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.
Diabetic Supplies and Equipment
Covered
Durable Medical Equipment &
Assistive Technology Devices
Covered
You have access to NJ FamilyCare benets
What Horizon NJ Health Covers
NJ FamilyCare Benet Description
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 identied 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
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Your Benets (continued)
You have access to NJ FamilyCare benets
What Horizon NJ Health Covers
NJ FamilyCare Benet Description
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
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,
• Methadone, Suboxone and Subutex 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
You have access to NJ FamilyCare benets
What Horizon NJ Health Covers
NJ FamilyCare Benet Description
Mental Health Inpatient Hospital
Services (Including Acute Psychiatric
Hospitals)
Covered
Mental Health Outpatient Services
Covered
Mental Health – Home Health
Covered for DDD, FIDE-SNP and MLTSS members. All other members are
covered by NJ FamilyCare Fee-for-Service.
Nurse Midwife
Covered
Nurse Practitioner
Covered
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
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 signicant vision changes occur. Contact lens exams and ttings 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.
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Your Benets (continued)
The following services may be available to you when assessed as
a need and identied in your Plan of Care:
Service Description
Acute Partial Hospitalization
(Mental Health)
Services that provide a non-residential psychiatric rehabilitation program for
members with serious mental illness
Adult Family Care
Living in the home or apartment of a trained caregiver who provides support
and services to the member
Adult Mental Health Rehabilitation
(AMHR)
A supervised residential group home that provides mental health services
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
You have access to NJ FamilyCare benets
What Horizon NJ Health Covers
NJ FamilyCare Benet Description
Prosthetics
Covered
Radiology Services
(Diagnostic & Therapeutic)
Covered
Rehabilitation Services (Outpatient
Physical Therapy, Cognitive
Rehabilitation Therapy Occupational
Therapy and Speech Pathology)
Covered
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.
Substance use
(Inpatient and Outpatient)
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 12:00 p.m. at least 48 hours in
advance of a routine transportation need.
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Your Benets (continued)
The following services may be available to you when assessed as
a need and identied in your Plan of Care: (continued)
Service Description
Inpatient Psychiatric
Hospital Care
Mental health care services that you get in a hospital that requires you to be
admitted as an inpatient
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
Opioid Treatment Services
Medication for maintenance and/or detoxication in combination with
substance use disorder counseling in a licensed treatment facility
Outpatient Mental Health Clinic/
Hospital Services
Mental health services provided in a community setting for members with a
psychiatric diagnosis
Partial Care Services
Non-residential recovery and clinical services to help individuals with severe
mental illness get back into having a successful role in the community and
avoid hospitalization and relapse (e.g., counseling, pre-vocational services)
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 Modications
Physical adaptations to a member’s private primary residence necessary to
ensure health and safety (e.g., wheelchair ramp)
Respite (Daily and Hourly)
A benet 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
The following services may be available to you when assessed as
a need and identied in your Plan of Care: (continued)
Service Description
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 Modications
Modications to a member or family vehicle to allow greater independence
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Services not covered by
NJ FamilyCare Fee-for-Service
or Horizon NJ Health
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 benet system or
third-party liability.
• Any service covered under any other
insurance policy or other private or
governmental health benet 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 ofce 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
reect 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 beneciary income to make up
for those costs. If nancial 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
benets are available from any workers’
compensation law, temporary disability
benets law, occupational disease law or
similar law.
Dental services
Good oral health is important to your body’s
overall health. You should visit your dentist at
least twice a year for an oral exam and cleaning.
Children should have their rst visit with a dentist
at age one or soon after the eruption of the rst
tooth. Be sure to complete all recommended
treatment.
You do not need a referral from your PCP to see
a dentist, and your dentist does not need prior
authorization from Horizon NJ Health for routine
dental care, such as cleanings, llings and X-rays.
Some dental services such as crowns, dentures
and root canals may require prior authorization.
Ask your dentist about this requirement. If you
need to make an appointment with a dental
specialist, use the online provider directory for
a list of participating dental specialists. No prior
approval is necessary to see a dental specialist.
Contact Member Services at 1-844-444-4410
(TTY 711) if you need to see a non-participating
dental specialist.
Vision services
Members are covered for routine eye exams
every one or two years based on their age and
health. You do not need a referral from your PCP
for routine eye care. If you need more exams
during the year or you need to see a vision
specialist, such as an ophthalmologist, you will
need to get a referral from your PCP.
Members with diabetes can have an eye exam
every year, which should include a dilated retinal
eye exam (DRE).
Vision services are available only from
participating Horizon NJ Health eye doctors.
Check the Provider Directory for a list of eye
doctors.
Laboratory services
LabCorp is the laboratory services provider for
Horizon NJ Health members. Your doctor will
give you a prescription for laboratory testing.
Take that prescription and your Horizon
NJ Health member ID card when you get lab
work done.
You can use the Horizon NJ Health Provider
Directory to nd a LabCorp location near
you. LabCorp also offers online appointment
scheduling at all New Jersey Patient Service
Centers. Visit LabCorp.com/PSC to nd a
location. Walk-in patients are also welcome.
Your doctor will give you your lab test results. Or,
you can use LabCorp Patient, an online service,
to download and print your test results on your
own. Visit patient.labcorp.com to register.
LabCorp will give your test results to your doctor
before posting them to your online account.
Prescription services
Horizon NJ Health covers many medications
that are offered to you at a low cost. These
approved drugs make up our formulary. If your
doctor wants to prescribe a drug that is not
included in our formulary, he or she will need
to call us to get prior authorization, or approval
in advance. It is important that the medications
you take are safe and effective. That is why
Horizon NJ Health has a committee made up of
practicing doctors and pharmacists who review
and approve our formulary. Some medications
are not covered under your pharmacy benet
and they include, but are not limited to, the
following: fertility agents, weight loss drugs
and erectile dysfunction medications. Certain
over-the-counter (OTC) products are covered
with a written prescription (for example,
Loratadine, Alaway, Zaditor OTC, Omeprazole,
Lansoprazole, smoking deterrents).
Your Benets (continued)
Words to Know
Ophthalmologist: A doctor who treats people with eye problems, eye
diseases and does eye surgery
Prescription: An order written by a doctor for a drug, test or other health
service
Formulary: A list of approved medicines that Horizon NJ Health covers
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For members residing in a long-term care facility,
OTC medications are generally provided by the
institution, rather than Horizon NJ Health.
Horizon NJ Health requires the use of generic
medicine when available. If your doctor decides
that you must have a medicine that is not in the
formulary, including a brand-name medicine
exception, he or she can ask for special
permission for you to get the medicine. While
you are waiting for a response, the pharmacy can
provide a 72-hour supply of the medicine. The
Horizon NJ Health Pharmacy department will
work with your doctor to fulll your prescription
needs. If you have questions, call toll free
1-844-444-4410 (TTY 711).
You can have prescriptions lled at any
participating pharmacy. For a list of pharmacies
or to nd the pharmacy nearest to you, call
Member Services. Participating pharmacies
are also listed in the Provider Directory
and in the Doctor & Hospital Finder at
horizonNJhealth.com.
The Approved Drug List (formulary) is updated
quarterly and as changes are made or new
medications are approved. The Approved Drug
List is updated as of the date that formulary
changes are put in place. Changes to this list
are included in the member newsletter, which
is mailed quarterly to all members. Covered
pharmaceuticals, including those that require
prior authorization, are listed on our website
at horizonNJhealth.com, under the Member
Support tab, click Resources, then click
Covered Drugs. There is no copayment for your
prescription drugs.
In general, Horizon NJ Health allows up to a
30-day supply for drugs. If you are currently
in a long term care facility, there is generally a
maximum of a14-day drug supply eligibility. A
supply of greater than 14 days is permitted for
certain units of medication (for example, eye
drops). If you live in a long term care facility,
the use of institutional sized drug products, for
example, insulin, will be utilized where available.
The website also has information on
pharmaceutical management procedures,
including the formulary listing, policies and
limitations. Limitations include quantity, plan,
supply/ll, step therapy and age. Paper copies
of the pharmaceutical management procedures
are available by contacting the Pharmacy
Department at 1-844-444-4410 (TTY 711).
Pharmacy Lock-In Program
Members who see different doctors may have
many types of medicine prescribed to them.
This can be dangerous. The Pharmacy Lock-In
Program coordinates a member’s care between
pharmacies and doctors. To make sure your
pharmacy care is coordinated, you should use
only one pharmacy to ll your prescriptions.
This will let the pharmacist learn about your
health and be better able to help you with
your medicine needs. Members who use many
pharmacies or doctors may be reviewed each
month to make sure that they are getting the
proper care. If it is decided that using only one
pharmacy will help the member get better
care, the member may be “locked-in” to one
pharmacy. We will send letters to the member,
pharmacy and doctor when a Pharmacy Lock-in
program is needed.
Medical transportation
Horizon NJ Health will provide emergency
ground or air transportation for MLTSS members.
All non-emergency medical transportation
services will be provided by LogistiCare. If you
need special services or transportation for
your medical care, you can call LogistiCare at
1-866-527-9933 (TTY 1-866-288-3133). For
livery service, such as car service to a medical
appointment, etc., you can also call LogistiCare
for reservations. There is a 20 mile limit for
transportation to your provider, unless an
authorization is provided for ofces outside this
radius. You should call by noon at least two days
in advance of your transportation need. After
your medical appointment is over, if you have
not scheduled a pickup time, you or someone at
the doctor’s ofce can call the Where’s My Ride
phone number at 1-866-527-9934 (TTY 711)
and request that transportation be sent to pick
you up. The transportation provider will pick you
up within 90 minutes.
To report any problems with your transportation,
call LogistiCare at 1-866-333-1735. You may
also visit the LogistiCare website at
wecare.logisticare.com, where you can
complete an online form. LogistiCare will
respond to your issue.
Remember – do not call an ambulance for
routine transportation.
Behavioral health services
Horizon Behavioral Health provides behavioral
health benets for members. You do not need
a referral from your PCP to see a mental health
or substance use disorder provider. If you need
medicine for mental health and/or substance use
disorder, your mental health and/or substance
use disorder provider can prescribe the medicine
for you. Contact a behavioral health provider
or inform your MLTSS Care Manager if you are
experiencing the following:
• Constantly feeling sad
• Feelings of hopelessness or helplessness
• Trouble sleeping
• Poor appetite
• Loss of interest in things you once enjoyed
• Difculty concentrating
• Irritability
Utilization management
Horizon NJ Health wants to make sure you
receive the right care for your problem, in the
right setting. To do this, we have a Utilization
Management (UM) team that works in
collaboration with your MLTSS Care Manager to
ensure that you get timely, efcient and quality
service from doctors, hospitals, dentists and
other providers.
Horizon NJ Health helps with referrals to
specialists, admissions, discharges and length
of stay issues when a member is admitted to a
hospital or ambulatory surgical center. We give
doctors information about our care and disease
management programs when necessary.
Most of all, we work with your PCP or specialist
to ensure that you get the continuous care you
need. Horizon NJ Health has special staff who
can help you with UM questions. If you have
questions about our UM process, please contact
your MLTSS Care Manager or MLTSS Member
Services at 1-844-444-4410 (TTY 711).
Your Benets (continued)
Words to Know
Ambulatory surgical center: A site that provides surgical care but does
not provide care overnight
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