You may enroll by printing the enrollment form and mailing it to:
Horizon Blue Cross Blue Shield of New Jersey PO Box 10138 Newark, NJ 07101-9633
This is a Medicare Advantage plan and I will need to keep my Parts A and B. I can be in only one Medicare Advantage plan at a time. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. Enrollment in this plan is generally for the entire year. I may leave this plan only at certain times of the year, or under certain special circumstances, by sending a request to Horizon Healthcare of New Jersey, Inc. or by calling 1-800-Medicare. TTY users should call 1-877-486-2048, 24 hours per day, 7 days per week. This plan serves a specific service area. If I move out of the area that this plan serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of this plan, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from this plan when I receive it to know which rules I must follow in order to receive coverage with this Medicare Advantage plan. I understand that Medicare beneficiaries are generally not covered under Medicare while out of the country except for limited coverage near the U.S. border. I understand that beginning on the date this plan coverage begins; I must get all of my health care from that plan with the exception of emergency or urgently needed services or out-of-area dialysis services. Services authorized by the plan and other services contained in my Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR THE PLAN WILL PAY FOR THE SERVICES.