BCBS AFFILIATENJPBM: Prime Therapeutics
Horizon BCBS New Jersey Prior Authorization Guide
Submit prior authorization requests and appeal denials with Horizon BCBS NJ. Phone numbers, fax numbers, appeal deadlines, step therapy override rights, and clinical documentation tips for NJ providers.
Prior Authorization Contacts
PA PHONE
1-800-664-2583
PA FAX
1-973-274-2226
TURNAROUND
30 days standard, 72h expedited
TIMELY FILING
180 days
APPEALS MAILING ADDRESS
Horizon BCBSNJ Appeals, PO Box 820, Newark, NJ 07101
Common Denial Reasons
- ⚠ Horizon Medical Policy criteria not met
- ⚠ Step therapy required
- ⚠ OMNIA tier assignment (narrow network)
- ⚠ Non-formulary
Step Therapy Requirements & Override Rights
New Jersey AB 2431 (2019) established step therapy override requirements. Horizon must respond within 72 hours. For biologics, typically requires 3-month DMARD trial per Medical Policy.
Tips for Horizon BCBS NJ Submissions
- 1. NJ AB 2431 provides step therapy override rights
- 2. OMNIA tier affects cost-sharing but not PA coverage criteria
- 3. Submit via NaviNet
- 4. Reference Horizon Medical Policy number
External Review Authority
If Horizon BCBS NJ denies your final internal appeal, you have the right to request an external review through: New Jersey Department of Banking and Insurance (IHCAP).
External review decisions are binding on the insurer.