Stop smoking, save money

Medical plan guidelines for lung cancer treatment

DHMO treatment for procedure not in the brochure

Q. I am paying the additional $12.50 biweekly premium – $300 more per year – for my medical coverage, because my wife smokes. Does the higher rate apply just to smokers or to anyone using tobacco? Does the HMO cover “stop smoking” programs? How can I stop paying the higher premium?

A. The additional $12.50 biweekly premium applies to anyone using tobacco products. Anyone who uses cigarettes, snuff, chewing tobacco, cigars or pipe tobacco is a tobacco user.

The HMO, POS and Out-of-Area plans pay up to $185 for one course of treatment annually for prescription drugs that help people quit smoking. Each plan’s prescription drug benefit applies.

A plan member must stop smoking for at least 60 consecutive days to remove the “tobacco user” designation.

After 60 days of not smoking, you have 31 days to complete and submit a voluntary disease prevention discount form to the benefits division, 611 Walker, 4th floor.

After the benefits division processes your form, you will stop paying the $12.50 biweekly premium. You will not receive a refund for the higher premiums you paid.

If you do not apply to stop paying the tobacco user’s rate within 31 days of your 60-day nonsmoking period, you must wait until the annual open enrollment in March and April. Then, the effective date for the lower premium is May 1.

Q. I have been diagnosed with early-stage lung cancer. What are our medical plan’s guidelines for proper treatment and payment?

A. HMO and POS members who use network providers must get a primary care physician’s referral to a cancer specialist within the PCP’s group, except in emergency situations. Kelsey-Seybold members do not need a referral from their PCP and may self-refer to specialists within Kelsey-Seybold.

You may ask your PCP to authorize a second opinion. You must get the second opinion before beginning a treatment plan with an oncologist.

After selecting an oncologist to direct your care from the same group as your PCP, return to your PCP for authorization to receive treatment from the oncologist.

The oncologist and you will choose a treatment plan. The oncologist will direct your cancer treatment until he or she releases you or decides another specialist can treat your illness better.

Each visit to the oncologist and for chemotherapy or radiation costs the regular office visit copay: $20 for HMO and $30 for POS in-network. POS out-of-network covers 60 percent of the expenses after the annual deductible. The Out-of-Area plan covers 70 percent of the expenses after the annual deductible.

Your PCP is responsible for the paper work involved in referrals to specialists. You may check the status of authorizations with HMO Blue Texas representatives in the benefits division, 611 Walker St., 4th floor. Call (713) 837-9376, (713) 837-9377 or (713) 837-9448.

Q. My dentist in the National Pacific Dental plan DHMO network wants to perform a procedure not listed in the DHMO brochure. Will I have to pay the entire cost?

A. The DHMO brochure has a complete list of dental procedures and copayments covered under the DHMO plan. If you agree to a procedure not listed there, you will pay the entire cost.

If you have any questions about your copayments, ask your dentist before you receive services or call National Pacific Dental customer service, (713) 861-8721 or (800) 292-0330.

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Pulse readers can get answers to their medical, dental and insurance benefits questions from the Human Resources Benefits Division's customer service representatives. Nicola Stanley answers your questions in this issue.

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