Healthnewengland.com

PROGRAM VOUCHER
To obtain reimbursement (up to $50.00) for attending a smoking cessation class, call HNE to obtain a log number, fill out this form, cut along the dotted line and bring it to class with you. Mail the completed form to: Your Member ID Number:
_______________________________________
Call HNE
Your Log Number:
413-787-4000 or 800-842-4464
_______________________________________
HNE is behind you in your efforts to become and Your Name:
remain smoke free. In fact, we believe so strongly that quitting smoking will improve your quality of life and _______________________________________
overall health that, we will pay up to $50.00 for you to attend a smoking cessation class. This offer is available Class Dates and Location:
to HNE members who have diabetes, asthma, high _______________________________________
cholesterol, coronary heart disease, and/or are pregnant. _______________________________________
Many smoking cessation programs recommend the use _______________________________________
of nicotine replacement therapies (NRT or Zyban®) to supplement and support your efforts. Your doctor _______________________________________
(obstetrician if you are pregnant) should decide if these are safe options for you. Depending on your Health Class Instructor(s):
New England insurance policy, if you are enrolled in a Name: ________________________________
smoking cessation program, you may be eligible to get Phone: _______________________________
these medications for a limited time for a copay. (Individual coverage/copays vary by employer group). Name: ________________________________
Check with your Benefits Administrator for possible coverage of the following: Phone: _______________________________
Nicotrol® nasal sprayNicotrol® inhalerZyban®Chantix® HNE USE ONLY:
(Note: These medications, if covered, Effective Date: ___________________________
Group #: _______________________________
of doses per prescription and refills Paid Date: ______________________________
per calendar year. Call HNE forupdated information.) Check # ________________________________
For HNE members with diabetes, asthma, high cholesterol, coronary heart disease, pregnancy
Health New England Smoking Cessation Program Voucher •ENCLOSED•
hne.com
Baystate Medical Center, Springfield, MA
"Freedom from Smoking" (run by the Pulmonary Rehab Dept.)
413-794-2255, The Professionals
Cooley Dickinson Hospital, Northampton, MA
413-582-2649 or 413-582-2400, Sue Lesser, RN
Baystate Franklin Medical Center, Greenfield, MA
413-773-2454, Rose Deskavich, OTR
Berkshire Medical Center, Pittsfield, MA
413-499-2602, Carol McMahon, MS
Lung Disease Help Line
American Lung Association of Western, MA
(staffed by Nurses, Respiratory Therapists, Smoking Cessation Specialist)
lungusa.org
Noble Hospital, Westfield, MA
"Freedom from Smoking" (run by the Respiratory Therapy Dept.)
413-568-2811, Ext. 5731
Try-To-Stop Tobacco Resource Center of Massachusetts
800-trytostop (800-879-8678)
trytostop.org
Quitnet
quitnet.com
P.S. Will consider reimbursement for hypnosis programs up to $50 ONLY.

Source: http://www.healthnewengland.com/HNE_members/documents/SmokingCessationVoucher.pdf