Requirements for Non-Tobacco Use
Health Plan Premium Credit
Employer is providing our full-time employees a $50 monthly credit on their share of the health care
premium if they do not use tobacco products, or if they do so but certify that they have completed a
tobacco cessation program. The details of the program and eligibility are outlined below.
o
“Non-tobacco user” is defined as a person that has not used tobacco for at least twelve
months before the date they sign the document.
o If the person signing the document has used tobacco products in the last twelve
months they may receive the credit by registering for and completing an authorized
tobacco cessation program.
o Tobacco is defined as cigarettes, pipes, cigars, or chewing tobacco.
o
If it is unreasonably difficult due to a medical condition, or if it is medically inadvisable for the
employee to achieve the standards for the credit under this program, the employee is asked to
contact contact name, title, phone number to develop another way method to qualify for the
credit.
o
To qualify for the credit full-time employees enrolled on the health plan must certify that they
are non-tobacco users or they are tobacco users enrolled in a cessation program.
o
Employees can qualify for the credit once a year during open enrollment. If an employee
enrolled in the medical plan does not sign either of the two attached certification forms, the
employee will not receive the credit and will not be eligible to receive it until the next year’s
open enrollment period.
o
To receive the credit, full-time employees who use tobacco products must:
o Enroll in one of the programs listed by February 1, 2012. Enrollment in a program by
this date ensures the credit will be granted on the employee’s health care benefit
premium share effective July 1, 2012.
o Submit documentation of program completion to contact name in Human Resources by
December 8, 2010. If such documentation is not received by this deadline, Employer
will rescind the employee’s credit for the remainder of the year.
o
Providing inaccurate or false information to receive the credit will result in withdraw of the
employee’s credit for the remainder of the year.
Non-Tobacco Use Certification
I hereby certify that I have not used tobacco (cigarettes, pipes, cigars or chewing tobacco) for at
least twelve months before the date of this certification.
______________________________
Employee
_____________________________
Today’s Date
Please print the following information:
Employee Name
Work Phone
Email Address
Please keep a copy of this certificate for your records and send the original to Name, Title, by April
15, 2012 to receive the health plan premium credit effective July 1, 2012.
If you have any questions, please contact Name, Title, Phone Number.
Certification of Tobacco Cessation Program Completion
Please indicate which option(s) you have signed up for (you must attach proof of program
completion).
 CIGNA’s telephonic or online coaching tobacco cessation program at www.myCIGNA.com
 Telephonic Program
 1-866-417-7848
 Other: ___________________________________________
 A Tobacco Cessation class or support group sponsored by a local hospital
 Use of a Nicotine Replacement Therapy monitored by your physician
 Use of an Alternative Therapy (i.e. Hypnosis, Acupuncture) monitored by a Licensed Practitioner
Tobacco Cessation Program Participation Certification
I hereby certify that I have signed up for the above program, to help me quit using tobacco products.
__________________________________
Employee
_____________________________
Today’s Date
Please print the following information:
Employee Name
Work Phone
Email Address
Please keep a copy of this certificate for your records and send the original to Name, Title by
November 24, 2010 to receive the health plan premium credit effective January 1, 2010.
Documentation or program completion (i.e. certificate or letter) must be submitted by December 8,
2010.
If you have any questions, please contact Name, Title, Phone Number