TobaccoSurcharge
Effective January 1, 2014 the Board of Regents of the University System of Georgia approved a $50 monthly surcharge be added to the health insurance premiums of tobacco users covered by the University System of Georgia’s Health Care Plan. The elimination of tobacco use will reduce the cost to the insurance plans and, most importantly, keep USG employees healthy. This surcharge applies to active employees, USG retirees, and all covered dependents that are at least 18 years of age. If you or your covered dependents use tobacco, you will pay the additional surcharge of $50 per month for each tobacco user. Tobacco use is classified as smoking tobacco in such forms as a cigarette, pipe, or cigar; or using smokeless tobacco, such as snuff or chewing tobacco (nicotine chewing gum is excluded). All employees are required to certify whether they and all covered dependents age 18 and up are current tobacco users. 1. Log in to the ADP Benefits website 2. Complete and return the Tobacco Use Certification If an employee certifies they are a non‐tobacco user and it is determined they have used tobacco products or started using tobacco products after the date of certification as a non‐tobacco user, they will be subject to following including, but not limited to: 
Payment of the $50 surcharge, plus a 10% penalty, for each month since the certification Once an employee is tobacco‐free, they can apply for the non‐tobacco user premium by completing an updated Tobacco Use Certification or within the ADP Benefits system. TOBACCO USE CERTIFICATION FORM
Employee/Retiree Name: _______________________________
Employee ID: ________________ or Retirees – Institution retired from: ______________________
Tobacco Use Certification. A tobacco user is defined as any employee/retiree, spouse, or
dependent child(ren) 18+ who currently use tobacco products. “Tobacco products” include but are
not limited to cigarettes, cigars and chewing tobacco. This election can be changed only if you
certify that you or your covered dependents have stopped using tobacco products.
CHECK ONE (EMPLOYEE OR RETIREE)
o
I AM CURRENTLY A TOBACCO USER
o
I AM NOT A TOBACCO USER
LIST DEPENDENT NAME AND CIRCLE YES OR NO (COVERED DEPENDENTS AGE 18+)
DEPENDENT NAME
TOBACCO USER
YES OR NO
TOBACCO USER
YES OR NO
TOBACCO USER
YES OR NO
TOBACCO USER
YES OR NO
TOBACCO USER
YES OR NO
I do hereby attest that the above information is true and correct to the best of my knowledge. I
further acknowledge and understand that I may be subject to a fine of not more than $1,000 or
imprisonment for not less than one and no more than five years, or both, and I may lose health
coverage for one year, if I knowingly and willfully make a false or fraudulent statement or
representation to the Board of Regents of the University System of Georgia regarding the
information reported on this form or other information pursuant to O.C.G.A. Section 16-10-20.
I understand that if I (or any of my covered dependents) start using tobacco products after the
date of this certification I must recertify the tobacco use status immediately or I will be subject to
the penalties above.
Signature____________________________________ Date ______________________
Certification must be submitted to the USG Shared Services Center at: USG Shared Services
Center, 1005 George J. Lyons Parkway, Sandersville, GA 31082 or to your institution’s Human
Resources/Benefits office.
"Creating A More Educated Georgia"
www.usg.edu
Ready to stop smoking? Here’s how to get help.
Taking care of your health is important and we’d like to help you do that. If you smoke, one of
the best ways to improve your health is to stop smoking.
On average, adults who smoke die 13 to 14 years earlier than nonsmokers. Tobacco use remains the leading
preventable cause of disease, death, and disability in the United States.
Even secondhand tobacco smoke is deadly. It contains chemicals such as formaldehyde, ammonia, arsenic, carbon
monoxide and lead. Each year, about 3,400 nonsmoking adults die of lung cancer and another 46,000 nonsmokers
die from heart disease, all as a result of breathing secondhand smoke.
Take a look at all the health benefits of quitting:
• Within 20 minutes: Your heart rate drops.
• Within 12 hours: The carbon monoxide level in your blood is normal.
• Within 2 weeks to 3 months: Your circulation improves and your lung function returns to normal.
• Within 1 to 9 months: Your coughing and shortness of breath decrease.
• Within 1 year: Your risk of heart disease is about half that of a tobacco user.
• Within 5 years: Your risk of stroke equals that of a non-tobacco user.
How to find the right “quit” program for you
The program that works best for you may be different from the program that works best for someone else.
So talk to your doctor, who’s one of your best resources for finding programs that meet your total health needs.
Your doctor can talk about over-the-counter and prescription medications to you.
TIP: Studies show that stop-smoking programs that work best are those offered through a facility or doctor
and include therapy and social support.
Important Note:
Resources
Georgia Tobacco Quitline
877-270-STOP
St. Joseph’s Hospital
Knock Out Nicotine
Atlanta, GA
678-843-7454
American Cancer Society
800-ACS-2345
cancer.org
American Lung Association
quitterinyou.org
CDC-Tobacco Information
and Prevention Source
(TIPS)
cdc.gov/tobacco
800-QUIT-NOW
Kill the Can
killthecan.org
SmokeFree.Gov
smokefree.gov
877-44U-QUIT
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HEALTH CARE BASICS
A $50 Tobacco surcharge will apply
to your healthcare premium if you use
tobacco and a $50 tobacco surcharge
will apply per covered dependent age
18+ who uses tobacco.
Action Required!
Tobacco use certification is required upon
enrollment in the healthcare coverage in
2014. If you do not certify, your status will
default to tobacco user and a $50 surcharge
will be added to your premium.