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FOCUSHealthSPRING 2017 on

The magazine for Horizon Blue Cross Blue Shield of New Jersey members

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Six questions to ask whenyour doctor orders tests During an exam, your doctor mayrecommend that you undergo a test or procedure to better evaluatecurrent symptoms or to helpdiagnose an underlying medicalcondition. Learn which questions you should ask.

Access to quality careLearn the importance of choosing a doctor, hospital or health careprofessional that fits your health care needs.

ER visits: know before you goA reminder on why it’s important to know what your insurance coverswhen you seek care at the ER.

Urgent care centers:an alternative to the Emergency RoomDid you know that you can gettreated for wounds, sprains and other conditions at urgent carecenters? Learn more about urgentcare centers and how to find ones that participate with Horizon BCBSNJ.

Where to go in an emergencyLearn where to go when you arefaced with a true medical emergency.

Accessing home healthservicesLearn how you can access all homehealth care services through theHorizon Care@Home program.

Take advantage of no-cost flu shots and otherimmunizationsLearn how Horizon BCBSNJ isproviding greater access to flu shotsand other immunizations.

A healthy you takes twoLearn how your relationship with your doctor, including how well youcommunicate with each other, affectsyour care and health care goals.

Medical policies and priorauthorizationsLearn how Horizon BCBSNJ and its network of quality doctors, health care professionals andfacilities strive to provide you accessto appropriate medical care when you need it.

Is your doctor recommendingspinal surgery? Learn about a new process related to spinal surgery that ensures youreceive the right care at the right time.

Horizon BCBSNJ winsdiversity awardsWe’re proud to announce HorizonBCBSNJ received special recognitionfor our commitment to diversity andinclusion.

Lower your out-of-pocketexpenses by staying innetworkLearn how using doctors, hospitalsand other health care professionalswho participate in our network can save you money.

Does your doctor fit your needs?Learn how choosing a doctor who is responsible for helping youcoordinate your care is important to your overall health.

How healthy is your heart?Learn more about Coronary ArteryDisease and the importance ofknowing your family history.

Living with a chronic illness and depressionWhen you have a chronic illness,it’s normal to experience a range ofemotions. Physical and emotionalstress can impact your illness, andoften leads to depression. Learn how to recognize the common signsand symptoms of stress anddepression.

Referrals help your doctor manage your careLearn the role referrals play in how your doctor manages andcoordinates your care.

Researching new technologyand treatmentsRead more about how HorizonBCBSNJ reviews new medicaltechnology and treatments.

Taking control of yourdiabetesGetting regular care for yourdiabetes can help you preventfurther health complications such asheart disease, stroke, and eye, footor kidney problems. Learn how youcan make sure you are up to date inthe management of your disease.

When is your child too old for the pediatrician?Learn more about transitioning yourchildren who are age 18 to 21 yearsto an adult care doctor.

HorizonBlue.com/focusVisit Focus on Health on the web at HorizonBlue.com/focus. You’ll find an electronic copy of this issue, as well as these important stories:

http://www.HorizonBlue.com/focushttp://www.HorizonBlue.com/focushttps://www.horizonblue.com/members/education-center/focus-on-health/six-questions-to-ask-when-your-doctor-orders-testshttps://www.horizonblue.com/members/education-center/focus-on-health/a-healthy-you-takes-twohttps://www.horizonblue.com/members/education-center/focus-on-health/how-healthy-your-hearthttps://www.horizonblue.com/members/education-center/focus-on-health/access-to-quality-carehttps://www.horizonblue.com/members/education-center/focus-on-health/medical-policies-and-prior-authorizationshttps://www.horizonblue.com/members/education-center/focus-on-health/living-a-chronic-illness-and-depressionhttps://www.horizonblue.com/members/education-center/focus-on-health/er-visits-know-before-you-gohttps://www.horizonblue.com/members/education-center/focus-on-health/your-doctor-recommending-spinal-surgeryhttps://www.horizonblue.com/members/education-center/focus-on-health/referrals-help-your-doctor-manage-your-carehttps://www.horizonblue.com/members/education-center/focus-on-health/urgent-care-centers-an-alternative-to-emergency-roomhttps://www.horizonblue.com/members/education-center/focus-on-health/horizon-bcbsnj-wins-diversity-awardshttps://www.horizonblue.com/members/education-center/focus-on-health/researching-new-technology-and-treatmentshttps://www.horizonblue.com/members/education-center/focus-on-health/where-to-go-an-emergencyhttps://www.horizonblue.com/members/education-center/focus-on-health/lower-your-out-of-pocket-expenses-by-staying-networkhttps://www.horizonblue.com/members/education-center/focus-on-health/take-control-of-your-diabeteshttps://www.horizonblue.com/members/education-center/focus-on-health/accessing-home-health-serviceshttps://www.horizonblue.com/members/education-center/focus-on-health/does-your-doctor-fit-your-needshttps://www.horizonblue.com/members/education-center/focus-on-health/when-your-child-too-old-for-pediatricianhttps://www.horizonblue.com/members/education-center/focus-on-health/take-advantage-of-no-cost-flu-shots-and-other-immunizations

5 Our Care Management Program

6 Learn more aboutyour pharmacy benefits

10 Find participatingdoctors and hospitalsin and outside of New Jersey

12 Keeping your adultchildren on your plan

13 Tackling opioid abuse14 You may need a

vaccine if ...17 Your health plan

information is just aclick away

18 Is it the baby blues —or something more?

20 Horizon Hospital Network continues toexpand

24 Women’s Health andCancer Rights Act

Your health care news across the regionHorizon Blue Cross Blue Shield of New JerseyEditor: Robyn BennettManaging Editor: Paul SalusDesign & Layout: Jose AlarconDirector: Daisy Chan

Services and products may be provided through Horizon Blue Cross Blue Shield of New Jersey, Horizon Healthcare of New Jersey, Inc., Horizon Insurance Company or Horizon Healthcare Dental, Inc., independentlicensees of the Blue Cross and Blue Shield Association. Focus on Health magazine is written exclusively for Horizon Blue Cross Blue Shield of New Jersey members by the Enterprise Communications departmentof Horizon BCBSNJ. This magazine provides basic coverage guidelines to help you maximize your health care benefits. It provides general preventive health and wellness guidelines, as well as information onmanaging specific health conditions. Please read this magazine and use it to help make informed health decisions. You can discuss the enclosed information, which is not medical advice, with your doctor. Theinformation in Focus on Health is for educational purposes only and does not replace your doctor’s medical advice. Your doctor can diagnose a medical condition and help you make health choices that are right foryou. If you would like to comment on the information enclosed in this magazine, please write to: Enterprise Communications, c/o Paul Salus, Horizon BCBSNJ, 1427 Wyckoff Road, WL-03T, Farmingdale, NJ 07727.

Horizon Blue Cross Blue Shield of New Jersey is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross®and Blue Shield® names and symbols, BlueCard® and Blue Distinction® 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. ValueOptions of New Jersey, Inc., an independent New Jersey corporation licensed by the New Jersey Department of Banking & Insurance, is contracted by Horizon BCBSNJto administer the Horizon Behavioral Health program. Prime Therapeutics LLC supports Horizon Blue Cross Blue Shield of New Jersey in the administration of prescription drug benefits. Prime Therapeutics LLC is independent from and not affiliated with Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross and Blue Shield Association. The Prime Therapeutics name and symbol are registered marks of Prime Therapeutics LLC. Facebook® is a registered mark of Facebook, Inc. TwitterTM is a registered trademark of Twitter, Inc. WebMD® is aregistered trademark of WebMD, Inc. NaviNet® is a registered trademark of NaviNet, Inc. All other trademarks and service marks are theproperty of their respective owners. © 2017 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105.

3CMC0009440 (0517)

HorizonBlue.com

This year, Horizon Blue Cross Blue Shield of New Jersey is celebratingour 85th Anniversary. Founded during the Great Depression as theAssociated Hospitals Incorporated of Essex County, our Company wasthe first multi-hospital service plan to begin providing pre-paidhospital coverage. We have been a New Jersey-based company eversince, providing health coverage to generations of families andbusinesses in our great state.

For more than eight decades, Horizon BCBSNJ has been at theforefront of health care. We have worked to ensure that the changinghealth care needs of our customers have been met with innovativeand effective solutions. Providing security, peace of mind andaffordable, quality health insurance has always been, and remainstoday, our top priority.

We are the Company you can count on to transform health care inNew Jersey. To improve the quality of care you receive. To improveyour health care experience. To make health care more affordable.We’re proud to have served our customers for 85 years and we lookforward to continuing to serve you in the years ahead.

Robert A. Marino Chairman, CEO & President

In this issue

http://www.HorizonBlue.com

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When there are so many high-quality, in-network doctors, hospitals and other healthcare professionals to choose from, it’s good toknow that the Online Doctor & Hospital Findercan help you find the right doctors quickly andeasily.

It’s easy! Visit HorizonBlue.com/doctorfinder and:F Select the type of health care professional

you are looking for.

F Next, select your plan from the Choose a Plan to Start dropdown menu.Not sure which plan you have? Check thefront of your member ID card.

F Narrow your search by using one of thefilters. You can filter by distance from yourselected location, gender, languagespoken and more.

F New! Search by Doctor AffiliationSimply enter the name of a group practicein the Doctor Affiliation field for a list of allthe doctors that participate in the group.

Want to know what doctors can care foryou at one of our in-network hospitals? Justenter the name of the hospital in theDoctor Affiliation field for a list of all thedoctors that can care for you at the facility.

Access our Online Doctor & Hospital Finderat HorizonBlue.com/doctorfinder.

Find an in-network doctor, hospital or other health care professional Remember, you pay less out of pocket when you get healthservices fromdoctors, hospitalsand other health careprofessionals thatare in network for your Horizon BCBSNJhealth plan.

http://doctorfinder.horizonblue.com/http://doctorfinder.horizonblue.com/

Our Care Management Program

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The program focuses on:F Chronic Kidney Disease (CKD)

F End-Stage Renal Disease (ESRD)

F High-risk maternity care

F Oncology

F Supportive care

F Transplant case management

F Other general and pediatricconditions

Our Care Managers can:F Provide you with information to

help you make decisions about your health care.

F Help you with getting priorauthorizations for services.

F Refer you to other valuable programsor services when needed, including our Chronic Care Program (see articleto the right).

F Give you information on communityresources and other health andwellness programs.

To participate:You may be referred by your health careprofessional’s office, request servicesyourself or be invited to participatebased on claims data. All medical andpersonal information is confidential andshared only with those involved in yourcare. Consider discussing this free, voluntary program with your doctor.

For more information about our CareManagement Program, or to enroll,please call 1-888-621-5894 and select prompt 2 or visit HorizonBlue.com/case-management.

Help is availablefor your chronicconditionDo you need help managing achronic health condition? If so,enroll in our Chronic CareProgram.1

It’s a free, voluntary programthat promotes healthy living foreligible members who havebeen diagnosed with one ormore of these chronicconditions:

F Asthma

F Chronic Kidney Disease(CKD)

F Chronic ObstructivePulmonary Disease (COPD)

F Coronary Artery Disease(CAD)

F Diabetes

F Heart failure

To learn more about ourChronic Care Program or toenroll, call 1-888-334-9006,Monday through Friday,between 8 a.m. and 7 p.m., Eastern Time, or visit HorizonBlue.com/chronic-care.

1 Not all programs are available to allmembers. Please check with yourbenefits administrator to see if you are eligible for this program.

1 Not all programs are available to all members. Please check with your benefits administratorto see if you are eligible for this program.

If you have a serious or complex medical condition, Horizon BCBSNJ’s Care ManagementProgram1 helps you get the care and services you need. Our specially trained CareManagers will help coordinate your health care services with your doctor.

https://www.horizonblue.com/members/plans-services/case-managementhttps://www.horizonblue.com/members/plans-services/chronic-care-program

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Find out if yourmedicine has aquantity limit orrequires priorauthorization.

One convenient source for all your pharmacy needsOur pharmacy benefits manager, PrimeTherapeutics, provides a wealth of informationand tools to help you get the most from yourpharmacy benefits.1 You can learn more aboutwhich generics are available, how to enroll inprescription home delivery service, or find aparticipating pharmacy in your area.

To access the Prime Therapeutics website,sign in to Member Online Services atHorizonBlue.com/members. Click Get Carefrom the Home page, then click PharmacyServices. When you click Continue, you’ll bedirected to Prime Therapeutics.

Determine which medicines your plan coversOur formularies (lists of covered prescriptionmedicines) are available to view online atHorizonBlue.com/members, and areupdated regularly as changes are made. Youcan quickly and easily find out whichmedicines are included in your plan’sformulary. Sign in to Member Online Servicesat HorizonBlue.com/members, click Get Carefrom the Home page, then click PharmacyServices. Click Continue to be directed toPrime Therapeutics.

1. From the top navigation bar, clickMedicines and select Find medicinesfrom the dropdown menu.

2. From the Your Medicines page, scroll downthe page to the Helpful documents sectionand click the drug formulary link, which will display your plan’s formulary guide.

3. You can also search by medicine name.If you do not have access to a computer,call Pharmacy Member Services at 1-800-370-5088 to have a copy of yourplan formulary mailed to you.

Learn more about your pharmacy benefits

(continues on next page)

https://www.horizonblue.com/membershttps://www.horizonblue.com/membershttps://www.horizonblue.com/members

Does your medicine have a quantitylimit or does it require a priorauthorization?You can find a lot of information abouthow your medicines are covered. Sign into Member Online Services atHorizonBlue.com/members, click GetCare from the Home page, then clickPharmacy Services. Click Continue to bedirected to Prime Therapeutics.

To find out if a medicine has aquantity limit or requires a priorauthorization: 1. From the top navigation bar, clickMedicines and select Find medicinesfrom the dropdown menu.

2. From the Your Medicines page, scrolldown the page to the Helpfuldocuments section and click the drug formulary link.

3. The drug formulary will indicate whichmedicines have quantity limits orrequire a prior authorization.

How can your doctor submit anelectronic request for priorauthorization (PA), quantity limit (QL)review, or tier exception (TE):1. From the top navigation bar, clickForms and select Plan documentsfrom the dropdown menu.

2. From the Get the forms you needpage, scroll down the page to thePrior Authorization/Medical NecessityDetermination, Quantity Limits, or Tier Exception sections and click theView forms & instructions link.

3. Click on the Click Here to Complete Your Prior AuthorizationElectronically links to be directed toNaviNet® for electronic submission.

In addition, your doctor can also submitPA, QL or TE requests:

By phone:By calling Prime Therapeutics at 1-888-214-1784.

By fax:By using the downloadable forms from the Get the forms you need pageand faxing them to Prime Therapeutics at 1-877-897-8808.

By mail: Horizon Blue Cross Blue Shield of New Jerseyc/o Prime Therapeutics LLC, Clinical Review Department1305 Corporate Center DriveEagan, Minnesota 55121

1 Only available to members who have pharmacybenefits from Horizon BCBSNJ.

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New homedeliveryprescriptionserviceHorizon BCBSNJ’s pharmacy benefit manager, PrimeTherapeutics, has partnered withWalgreens Mail Service for homedelivery of prescriptions.1 Thismeans, if you have HorizonBCBSNJ pharmacy benefits anduse home delivery, Walgreens Mail Service pharmacy now fills your prescriptions instead of PrimeMail.

The new service, PrimeMail byWalgreens Mail Service, giveshome delivery users the sameconvenient service, and does notaffect our retail pharmacynetwork. Members can continueusing the same in-network retailpharmacies. Learn more aboutHorizon BCBSNJ's home deliveryprescription service atHorizonBlue.com/homedelivery.

1 Only available to members who havepharmacy benefits from HorizonBCBSNJ.

Learn more about your pharmacy benefits(continued from page 6)

https://www.horizonblue.com/membershttps://www.horizonblue.com/members/plans-services/horizon-pharmacy/home-delivery-pharmacy-service

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Want to know how we use and protect your private information?Annual Privacy Notice

Horizon BCBSNJ is required to periodically notify members of the availability of our Noticeof Privacy Practices, which can be found at HorizonBlue.com/privacy-policy.The Notice contains important information about how Horizon BCBSNJ uses, discloses andprotects member information, as well as rights that members have regarding theirprotected health information.

In addition, Horizon BCBSNJ complies with applicable federal civil rights laws and does notdiscriminate on the basis of race, color, national origin, age, disability or sex. You can readour full nondiscrimination notice on page 21.

Your rights and responsibilitiesAs a Horizon BCBSNJ member, you have rights. These include the right to receive information aboutHorizon BCBSNJ’s services, policies and procedures, products, networks, appeal procedures, coveragelimitations and other information you need to understand your benefits and get care.

You also have responsibilities. These include reading and understanding member materials, includingyour member rights and responsibilities, and other materials that explain your coverage. You also needto provide, to the extent possible, information about your health that Horizon BCBSNJ, its networkdoctors and other health care professionals need to know to properly care for you.

To view a full list of your rights and responsibilities, visit HorizonBlue.com/rights.If you do not have internet access, you can call Member Services at 1-800-355-BLUE (2583) torequest a printed copy.

https://www.horizonblue.com/privacy-policyhttps://www.horizonblue.com/members/education-center/member-rights-and-responsibilities

Effective careHorizon BCBSNJ recognizesthat underusing and/oroverusing health care servicescan negatively impact youroverall health.

To respond to authorizationrequests and inquiries aboututilization management (UM),our UM staff is availableMonday through Friday,between 8 a.m. and 5 p.m.,Eastern Time. Simply callMember Services at1-800-355-BLUE (2583).TTY/TDD users can call 711.Our on-call staff is alsoavailable after normal businesshours, including weekends andholidays, for urgent priorauthorization requests.

Language assistance isavailable to those who need it.

How we make coverage decisionsHave you ever wondered how Horizon BCBSNJ makes coverage decisions?We want you to know that HorizonBCBSNJ:

F Makes utilization management (UM)decisions based on the medicalnecessity and appropriateness of careand service within the guidelines ofyour benefit coverage.

F Does not offer our employees, ordelegates performing medicalmanagement reviews, incentives toencourage denials of coverage orservice, and does not provide financialincentives to doctors to withholdcovered health care services that aremedically necessary and appropriate.

F Emphasizes access to the delivery ofmedically necessary and cost-effectivehealth care services for members.

F Encourages the reporting,investigation and elimination ofunderutilization or overutilization,both of which can result in costly andimproper uses of services, and are nothelpful to you.

• Underutilization is when you aren’tgetting enough care or services toproperly meet your needs.

• Overutilization is when you undergo treatments, tests andstudies that you don’t need.

For more information, please call Member Services at 1-800-355-BLUE(2583).

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Find participating doctors and hospitals inand outside of New Jersey

As a Horizon BCBSNJ member, you haveaccess to a broad network of qualityparticipating doctors, health care professionalsand hospitals.

Depending on your plan, you may choosefrom:

F More than 41,000 physicians and otherhealth care professionals, includingspecialty and behavioral health careprofessionals

F 78 hospitals in 96 locations in New Jersey,Pennsylvania and Delaware

Horizon BCBSNJ offers interactive tools andresources to help you find an in-network doctor based on your plan, compare hospitalsbased on specific diagnoses and procedures,and more.

Visit HorizonBlue.com to get started.

Living or traveling outside ofNew Jersey?Members enrolled in plans that includeBlueCard® benefits have access toparticipating doctors and hospitals throughoutthe country. Ninety-two percent of doctors and 96 percent of hospitals in the United States participate in the BlueCardProgram.1

To find doctors and hospitals available to youthrough the BlueCard Program:

1. Have your Horizon BCBSNJ ID card on hand.

2. Visit HorizonBlue.com/doctorfinderand select Doctors Outside of NJ within the What are you looking for? dropdownmenu.

3. Enter the required information and click Search.

Or you can call BlueCard Access at 1-800-810-BLUE (2583) for the names andaddresses of doctors and hospitals in the area where you or your covered dependentneed care.

Horizon BCBSNJmembers canchoose from awide variety ofphysicians andhospitals.

1 Please check your plan to find out if the BlueCard Program is available to you.Note: Network numbers are current at the time of printing.

http://www.HorizonBlue.comhttp://doctorfinder.horizonblue.com/

Mammogram While most women should begin annualmammograms at age 45 years, youshould start talking to your doctor at age40 years about when you should beginscreening. According to the AmericanCancer Society (ACS), women age 55years and older can switch to amammogram every other year, or theycan choose to continue yearlymammograms. Continue to talk to yourdoctor about how often you should bescreened. Regular mammograms shouldcontinue for as long as a woman is ingood health.

Pap testA regular Pap test as part of a cervicalexam is the most important screening infinding and treating cervical cell changesbefore they progress to cervical cancer.

Women between the ages of 21 and 29 years should have a Pap test every three years.

For women ages 30 to 65 years, thepreferred testing method is the HPV co-test (cytology and the HPV test areadministered together) every five years.Women older than age 65 years can stopscreening if there is an adequatescreening history. If you have certain risk

factors, you should continue to bescreened for cervical cancer asrecommended by your doctor.

Colon cancer screeningColorectal cancer is the second leadingcancer in the U.S. Regular screenings atage 50 years is the key to preventingcolorectal cancer. Screenings can alsofind colorectal cancer early, whentreatment is most effective. You mayneed to be tested earlier if you havecertain risk factors that put you at anincreased risk for developing colorectal cancer.

Prostate screeningThe ACS recommends that you shouldtalk with your doctor about theuncertainties, risks and potential benefitsof prostate cancer screening beforebeing tested.

If you are age 50 years, you should begintalking to your doctor about prostatecancer testing. If you are AfricanAmerican and/or have a family history of the disease, you should have this talk with your doctor starting at age 40 to 45 years.

Get healthy! You can help lower your chances of cancerby getting the recommended cancerscreenings and taking care of your health. Make healthy choices, every day!F Maintain a healthy weight F Stop smokingF Stay activeF Eat right

Sources: American Cancer Society, Centers forDisease Control and Prevention, U.S. Preventive Services Task Force

Are you up to date on your cancer screenings?Talk to your doctor today about scheduling these important cancer screenings. Your doctor will help you determine how frequently you need to receive them.

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Helping you getthe care you needwhen you need itWe are committed to helpingimprove your health. That’s whyHorizon BCBSNJ monitors andassesses the quality andappropriateness of careprovided to you by our in-network doctors and otherhealth care professionals.

We maintain access standardsto ensure that our membershave access to in-networkdoctors and other health careprofessionals.

To learn more about thestandards set for Primary CarePhysicians (PCPs), Ob/Gyns,specialty care doctors andbehavioral health practitioners,please visitHorizonBlue.com/membersand:

F Mouse over Our Network and select Providers

F Click Access Standards

If you have questions, or wouldlike a copy of this information,please call Member Services atthe phone number on the backof your Horizon BCBSNJmember ID card.

Sources: American Cancer Society, Centers for Disease Controland Prevention, U.S. Preventive Services Task Force

https://www.horizonblue.com/members

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Keeping your adult children on your planThis New Jersey mandate1 applies to qualifying dependents between the ages of 26 and 31 years.

Did you know that New Jersey law allows youto keep your children on your plan until theyturn 31 years old? This differs from theprovision in the Affordable Care Act thatrequires health plans to extend coverage fordependents to age 26 years. Under New Jersey law, qualifying dependentsbetween the ages of 26 and 31 years pay asmall premium to continue receivingdependent coverage.

The mandate defines a qualified dependentas the child of an insured subscriber, by bloodor by law, who:

F Is 30 years of age or younger;

F Is unmarried and not in a civil union or adomestic partnership;

F Has no dependents;

F Is either a New Jersey resident, or, if anonresident, is enrolled as a full-timestudent at an accredited school;

F Is not the insured person under a group orindividual health benefits plan or churchplan, or entitled to benefits underMedicare at the time health plancontinuation coverage begins; and

F Can provide evidence of prior creditablecoverage or receipt of benefits underanother group or individual health benefitsplan. (This is usually a written certificateissued by an insurer that shows the dates aprior health plan began and ended.)

1 This mandate does not apply to all plans. For additional eligibility and enrollment information, please contact your group administrator or call Member Services at 1-800-355-BLUE (2583).

Qualifyingdependents cancontinuereceivingdependentcoverage.

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Tackling opioid abuse

Horizon BCBSNJ has several programsand initiatives to help ensure ourmembers receive the right care at theright time without relying on opioids.

Support through pharmacy and other programs Horizon BCBSNJ provides resources andinformation to doctors to assist in safemedicine use and improving the qualityof care you receive. This information canalso help prevent abuse, addiction andfraud. Additionally, several initiatives fromour Horizon Pharmacy program integratepharmacy and medical claims to helpmembers and prescribers take action andmake informed decisions. Also,prolonged use of pain medication istracked through Horizon BCBSNJ’sEpisodes of Care programs.

Integrated services to help youThrough the Horizon Behavioral Healthprogram, we integrate medical,behavioral health and substance usedisorder services. This integration helpsensure treatment of underlying issues and keeps you healthy.

Support through communityengagement

F New Jersey Project Medicine DropHorizon BCBSNJ helps educatemembers and the public on how tocorrectly dispose of medicines.

F Partnership for a Drug-Free New JerseyThe Horizon Foundation for New Jersey supports the Partnershipfor a Drug-Free New Jersey, asubstance misuse and abuseprevention public health campaignthat provides free preventionprograms and initiatives to New Jerseyschools and communities, as well asparent education training and drug-free workplace assistance.

F Fifth Grade Parent AlertThe Horizon Foundation supports theFifth Grade Parent Alert, a brochureprovided to all fifth-grade classes inNew Jersey that encourages parentsand guardians to discuss the dangersof substance abuse with their children.

On February 15, 2017, New JerseyGovernor Chris Christie signed legislationaimed to curb the state’s opioid addictionepidemic. Horizon BCBSNJ is in theprocess of implementing legislativerequirements into our current programs.

Talk to your doctor Although many feel that drug addictioncould not affect them or their familiespersonally, as many as one in sixteenagers reported taking prescriptiondrugs to get high or change their mood.4

When either you or your child areprescribed pain killers, talk to the doctorabout the amount that is necessary tomanage the pain.

1 https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse

2 http://www.nj.com/news/index.ssf/page/welcome_to_herointown_new_jerseys_4th_largest_city.html 3 http://www.nj.com/news/index.ssf/2016/06/deaths_from_the_drug_that_killed_prince_are_skyroc.html#incart_river_home

4 Partnership for Drug-Free Kids. Heroin and Other Opioids [Online]. 2016. Available from: drugfreenj.org

Hear from theexperts onopioid abuseThe Horizon Foundation forNew Jersey, the philanthropicarm of Horizon BCBSNJ, isproud to sponsor thePartnership for a Drug-FreeNew Jersey (PDFNJ) Knock OutOpioid Abuse Town Hall Series.These meetings, to be heldthroughout the state throughNovember 2018, will help shedlight on opioid abuse, andprevention and awareness.They are based on the SurgeonGeneral’s recommendation togalvanize the public,policymakers and communitiesto raise awareness, educate,reduce stigma and changeattitudes on addiction and toultimately reduce and preventopioid abuse.

The Town Hall meetings willfeature speakers from PDFNJand The Horizon Foundation,panels of guest speakers toinclude local prosecutors andlegislators, and preventionspecialists among others. Tolearn more about the KnockOut Opioid Abuse Town HallSeries, and to see when a town hall will be held near you,please visitknockoutopioidabuse.drugfreenj.org.

With an estimated 2.1 million people in the U.S. suffering from substance use disordersrelated to prescription opioids,1 Horizon BCBSNJ is committed to preventing opioidmisuse and addiction. In New Jersey alone, high rates of addiction have claimed anestimated 5,000 lives in the past decade.2 Specifically, Fentanyl, an opioid up to 50 times more powerful than heroin, is killing New Jersey residents at a rate that istripling yearly.3

http://knockoutopioidabuse.drugfreenj.org/https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abusehttp://www.nj.com/news/index.ssf/2016/06/deaths_from_the_drug_that_killed_prince_are_skyroc.html#incart_river_homehttp://drugfreenj.org/http://drugfreenj.org/

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For instance, you may need a vaccine if ...You travel: International travelers are at risk fordiseases such as yellow fever, malaria and evenpolio. You can find out which vaccines arerecommended for your specific destination bychecking with the Centers for Disease Controland Prevention at cdc.gov. You should see yourdoctor at least two months before your trip.

Whether or not you need a given vaccine cangenerally depend on a variety of factors,including:

F If you’re traveling to an urban or rural area

F Length and season of your visit

F Lodging conditions (air conditioning, open-air tents, or screened-in house or room)

F Mode of travel and planned activities

F Common foods served in the area

For example, a business traveler who will be in urban areas for a couple of days may needdifferent vaccinations than a traveler to thesame country who plans to hike for a few weeksin the rainforest. Discuss your travel plans withyour doctor so he or she can recommend thebest vaccine for your situation.

You are injured: If you step on a rusty nail or arebitten by a wild animal, you may need a tetanusor rabies shot to prevent further complications,

depending on the date of your last vaccine.Consult your doctor immediately if your injurypresents risks for infection, so he or she canadvise you about any appropriate vaccines.

You anticipate a pregnancy or are pregnant:If you are planning on becoming pregnant, youshould be up to date on routine adult vaccines,particularly the measles, mumps and rubella(MMR) vaccine; this will help protect both youand your unborn child. If you need an MMRvaccine, your doctor may advise you to wait amonth after receiving it before becomingpregnant.

The inactivated flu vaccine is recommended forpregnant women since contracting the fluduring pregnancy can cause seriouscomplications. In addition, the adult tetanus,diphtheria and acellular pertussis vaccine (Tdap)is usually given between 27 and 36 weeks ofeach pregnancy a woman has.

You have a chronic condition: People withchronic health conditions can be moresusceptible to illnesses like the flu orpneumonia. If you have, for example, asthma ora heart condition, your doctor may stronglyencourage you to receive certain annualvaccinations.

Talk to yourdoctor to makesure you are upto date on yourvaccines.

You may need a vaccine if...There are many circumstances in which you may need an updateto your vaccinations

Sources:WebMD® ; Centers for Disease Control and Prevention, U.S.Department of Health and Human Services

https://www.cdc.gov/

Voicing a concernAny member who voices a concern, files a complaint orpursues an appeal will not be subject to disenrollment,discrimination or penalty by Horizon BCBSNJ.

If you get amedical billWhen you use a participatingdoctor or other health careprofessional, he or she filesclaims for you. You should notget a bill for covered expenses,except if your plan has acopayment or other membercost sharing, such as adeductible or coinsurance.

If you do not use a participatingdoctor, other health careprofessional or hospital, youmay get a medical bill. If youdo, please send a completedHorizon BCBSNJ claim formand the bill to the addresslisted on the claim form.Include your Horizon BCBSNJmember ID number, name, date of birth and yourrelationship to the patient, if applicable.

To download and print a claim form, visitHorizonBlue.com/forms. Or,call Member Services at 1-800-355-BLUE (2583).Once the claim is submitted,you can view the status bysigning in to Member Online Services atHorizonBlue.com.

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If you are ever dissatisfied with theoutcome of a claim or any aspect of yourplan coverage — including the quality ofcare or service you have received — you,your doctor, another health careprofessional or authorized representativeacting on your behalf (and with yourconsent) may file an inquiry, complaint orappeal with Horizon BCBSNJ. If you filean appeal, Horizon BCBSNJ will providea timely, fair and full investigation andresolution of your appeal. For a completedescription of our internal appealsprocess, please call Member Services at1-800-355-BLUE (2583).When deciding whether or not to file anappeal, please keep the following timeframes in mind:

F Members in a fully-insured plan mustappeal a benefits-based adverse claimdetermination within one year fromthe date of the claim determination.

F Members in a self-insured plan aregiven at least six months to appeal abenefits-based adverse claimdetermination. Please confirm thetime frame in your group’s SummaryPlan Description.

F If the appeal is not submitted toHorizon BCBSNJ in a timely manner,the insurer/claim administrator maynot accept the appeal request.

If you file an appeal and are dissatisfiedwith the resolution reached through ourinternal appeals process, you may callthe New Jersey Department of Banking& Insurance at 1-888-393-1062.You may also write to:

Office of Managed Care ConsumerProtection ServicesNJ Department of Banking & InsurancePO Box 329Trenton, NJ 08625-03291

https://www.horizonblue.com/members/forms/search-by-form-typehttp://www.HorizonBlue.com

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Have a question?Before you call, try these three secure and convenient ways to get your answers.

Need to knowwhat’s covered?Use our onlinetools to getanswers. 1. FAQs

Our online FAQs give you easy-to-followinstructions on how to find the informationyou need through Member Online Services.Simply visit HorizonBlue.com/faqs.

2. My Messages Use our online My Messages tool to send usyour questions. Simply sign in to MemberOnline Services at HorizonBlue.com andselect My Messages at the top of the screen.A Member Services Representative willrespond to your question within two business days.

3. Live ChatYou can chat with a Member ServicesRepresentative during normal business hours.Simply sign in to Member Online Services at HorizonBlue.com and click Live Chat. Horizon BCBSNJ’s online FAQs, My Messages and Live Chat are three toolsdeveloped with you in mind – making it easier for you to get the health coverageinformation you need.

Horizon BCBSNJ knows that your time is valuable. That’s why we offer three secure andconvenient ways for you to get information about your Horizon BCBSNJ benefits, enrollment,claims and more.

http://www.horizonblue.com/faqshttp://www.HorizonBlue.comhttp://www.HorizonBlue.com

Your health plan information is just a click awayGet 24/7 access to your benefit details, claims, healthand wellness support and more.Member Online Services gives yousecure, convenient access to your healthplan information. It also offers resourcesfor personalized health and wellnessadvice, and hands-on tools that help youget the most out of your health plan.

Sign in to HorizonBlue.com to:F Review your benefit details –

Information about your Primary CarePhysician (PCP), plan effective date,covered benefits, costs for in- andout-of-network services, if applicable,and more.

F View your claims – Review recentclaim activity, including any amount Horizon BCBSNJ paid and the amountyou owe, if applicable. You can alsosearch for claims by claim number, date and status.

F Manage your authorizations andreferrals – Search, view and print yourauthorizations and referrals.

F Access time-saving plan tools – Find participating health careprofessionals, print temporarymember ID cards, replace a lostmember ID card, download forms,ensure your information is up to date,and sign up to receive important plan information electronically.

F Learn more about your prescriptionplan – Our pharmacy tools1 can helpyou check medicine interactions, seewhich drugs are covered, orderprescriptions by mail and find ways tosave on prescription costs. Read thearticle on page 6 for moreinformation.

F Manage your dental plan details –Members who have Horizon BCBSNJdental benefit plans can check theireligibility, see dental claim status,request member ID cards and evenchange their dentists.

F Get personalized health and wellnesssupport – In addition to your healthplan information, you’ll enjoycomplimentary access to:

• Resources that will help keep you and your family healthy

• Educational articles on the latest health topics

• Instructional videos on how to make the most of Member Online Services

• Tools for tracking your personal health history

F Sign up for paperless Explanation of Benefits statements.

1 These tools are only available to members who have pharmacy benefits from Horizon BCBSNJ.

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At your doctor’soffice and forgotyour ID card? Don’t have your HorizonBCBSNJ member ID card withyou? No problem. Simply signin to Member Online Servicesat HorizonBlue.com from yoursmartphone, tablet orcomputer and click ID Cards.From there you can view andprint your Horizon BCBSNJmember ID card.

Once signed in, you also haveeasy and secure access toother important information, like claim status, what’scovered under your plan and more.

http://www.HorizonBlue.comhttp://www.HorizonBlue.com

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Is it the baby blues – or something more?The emotional changes a woman can feel after giving birthare usually part of a condition commonly called the “babyblues,” but sometimes those feelings can be somethingmore serious — postpartum depression.

The chart below from Horizon Behavioral Healthsummarizes the differences between the “baby blues,”feelings of sadness that ease after about two weeks

without intervention, and postpartum depression, aserious medical condition that should be diagnosed by adoctor for possible treatment.

After a woman gives birth, her doctor should screen herfor postpartum depression, but if at any time she or one of her loved ones feels her symptoms may be serious, she should contact her doctor immediately.

(continues on next page)This chart is for informational purposes only and is not a substitute for professional medical advice.

Causes Hormonal changes; exhaustion Hormonal and physical changes; exhaustion; feelingoverwhelmed about caring for a new child

Affects about 80 percent of those who have recently given birth

Affects approximately 10 to 15 percent of those who have recently given birth

Brief period after the birth of the baby; resolves after about two weeks without intervention

Can last up to a year after baby’s birth

• Feeling nervous or worried about being a good mother

• Mild sadness• Moodiness• Tired• Weepiness

• Feeling nervous or worried about being a good mother• Feeling angrier or more irritable with others• Feeling intense sadness, nervousness or panic• Feeling “out of control” or “crazy”• Having difficulty bonding with the baby• Having upsetting, persistent thoughts• Lack of interest in pleasurable activities• Problems eating or sleeping too much or too little• Trouble focusing, remembering or making decisions• Worrying about hurting the baby or oneself

Frequency

Duration

Symptoms

“Baby Blues” Postpartum Depression

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Improving thequality of your careAt Horizon BCBSNJ, we’recommitted to making sure youhave access to quality care.Our Quality ImprovementProgram (QIP) monitors andworks to improve the quality ofcare and services provided toyou. For more information onthe QIP, please visitHorizonBlue.com. Then:F Click About Us

F Click Company Reports

If you don’t have access to theinternet, please call the QualityManagement Department at 1-877-841-9629 to request a copy of the information.

Risk factors for postpartum depressionPostpartum depression can affect any woman who is pregnant, has given birth, suffereda miscarriage or has recently weaned a child from breastfeeding. Other risk factorsinclude:

F Having a prior history of depression

F Overwhelming demands

F Lack of support to help with the new baby

F Lack of sleep or becoming exhausted

F Not taking medications for depression before, during and/or after pregnancy

Getting helpF If you suspect you may have postpartum depression, talk about symptoms with

your doctor or health care professional right away. Don’t wait for your postpartumfollow-up appointment. Many treatment options are available, including counseling and medications.

F Talk with your spouse, partner, friends and family about how you are feeling.

F To locate a health care professional, visit Horizon BCBSNJ’s Online Doctor &Hospital Finder at HorizonBlue.com/doctorfinder or contact your mental healthservices provider at the number located on the back of your member ID card.

Additional resourcesF Postpartum Support International: 1-800-944-4PPD (4773); postpartum.net F National Institute of Mental Health (NIMH):

nimh.nih.gov/health/publications/postpartum-depression-facts/index.shtml F Substance Abuse and Mental Health Services Administration’s National Helpline:

1-800-662-HELP (4357)F U.S. Department of Health and Human Services, Office of Women’s Health:

womenshealth.gov/mental-health/illnesses/postpartum-depression.html F WebMD®’s Postpartum Depression Health Center:

webmd.com/depression/postpartum-depression/

Is it the baby blues – or something more?(continued from page 18)

http://doctorfinder.horizonblue.com/http://www.postpartum.net/https://www.nimh.nih.gov/health/publications/postpartum-depression-facts/index.shtmlhttps://www.womenshealth.gov/mental-health/illnesses/postpartum-depression.htmlhttp://www.webmd.com/depression/postpartum-depression/http://www.HorizonBlue.com

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Horizon Hospital Network continues to expand

St. Luke’s University Health Network On January 1, 2017, four additional hospitalsin St. Luke’s University Health Network (St. Luke’s) joined the Horizon HospitalNetwork. This includes its hospital campusesin Anderson, Bethlehem, Monroe andQuakertown, Pennsylvania.

St. Luke’s Warren location in Phillipsburg, New Jersey, is currently in the HorizonHospital Network.

HackensackUMC PalisadesOn January 1, 2017, HackensackUMCPalisades located in North Bergen, New Jersey, joined the Horizon HospitalNetwork.

You have a choice of network hospitalsthroughout New Jersey and nearby inPennsylvania and Delaware. As always, weencourage you to use network hospitals tolower your out-of-pocket costs.

To find a list of hospitals in the HorizonHospital Network, as well as participatingdoctors and other health care professionals,visit HorizonBlue.com/doctorfinder.

Horizon BCBSNJ continues to expand its hospital network and is pleased to announce severaladditions and changes. These agreements allow you to access care at an in-network level ofbenefits, maximize your benefits and minimize out-of-pocket costs.

You have a choice of network hospitalsthroughout New Jersey and nearby inPennsylvania and Delaware.

http://doctorfinder.horizonblue.com/

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Notice of NondiscriminationHorizon Blue Cross Blue Shield of New Jersey complies with applicable Federal civil rights lawsand does not discriminate on the basis of race, color, national origin, age, disability or sex.Horizon BCBSNJ does not exclude people or treat them differently because of race, color,national origin, age, disability or sex.

Horizon BCBSNJ provides free aids and services to people with disabilities to communicateeffectively with us, such as:

F Qualified sign language interpreters

F Information written in other languages

If you need these services, contact Horizon BCBSNJ’s Director of Regulatory Compliance at thephone number, fax or email listed below.

If you believe that Horizon BCBSNJ has failed to provide these services or discriminated inanother way on the basis of race, color, national origin, age, disability or sex, you can file agrievance with:

Horizon BCBSNJ – Director, Regulatory Compliance Three Penn Plaza East, PP-16C Newark, NJ 07105 Phone: 1-800-658-6781 Fax: 1-973-466-7759 Email: ComplianceAndEthicsOffice@HorizonBlue.com

You can file a grievance in person, or by mail, fax or email. If you need help filing a grievance,Horizon BCBSNJ’s Director of Regulatory Compliance is available to help you.

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 ComplaintPortal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, 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. 20201 1-800-368-1019 or 1-800-537-7697 (TDD)

Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.

https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf

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Information in other languages

23

Information in other languages

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The federal government mandates certain health coverage for breast reconstructive surgeryin any health insurance plan that provides medical and surgical benefits for mastectomies.

If your plan provides medical and surgical benefits for mastectomies, and you are receivingbenefits in connection with a mastectomy and choose to have breast reconstructionalong with that mastectomy, your plan must provide, in a mannerdetermined in consultation between you and the attendingdoctor, coverage for the following:

F All stages of reconstruction of the breast on which the mastectomy was performed

F Surgery and reconstruction of the other breast toproduce a symmetrical appearance

F Treatment of physical complications of the mastectomy, including lymphedema

F Breast prostheses, which is an artificial form ofa breast to help resemble its original form

These benefits are provided to the sameextent as any other illness under yourcoverage, subject to your deductible,coinsurance and copayment. All otherfeatures and benefits of your healthinsurance plan remain the same, andare not impacted by this notification.

Please refer to your benefit bookletfor more details on deductibles,copayments and coinsuranceapplicable to your healthinsurance plan.

Women’s Health and Cancer Rights Act