2021 Tobacco/Smoke Free Affidavit
If you use tobacco and will be covered under the medical plan offered by CCG in 2021, you must complete
a Tobacco Cessation Program to avoid the surcharge.
In an effort to promote and support the health and wellness of employees, the Columbus Consolidated Government will impose a
$75.00 per month or $34.62 biweekly surcharge above the premium rate for all active employees/Pre-65 Retirees Premium Plans
including the Silver and Gold Plan. This surcharge is subject to change annually. The surcharge applies to employees/Pre-65 retirees,
who are tobacco users. For purposes of the premium surcharge, “tobacco use” is defined as:
•
Using any tobacco product (other than for religious or ceremonial use) including cigarettes, cigars, pipes, electronic
cigarettes, vaping; tobacco products applied to the gums (e.g., dipping, chewing tobacco, or snuff)
•
Uses tobacco products on average four or more times a week
•
Within no longer than the past six months.
Employee Name: Last 4 digits of SS#
Please read all 3 options and check one:
tify
I hereby acknowledge and certify that I HAVE NOT USED, tobacco products, in any form, within the past six (6) months.
The $75.00 per month/$34.62 biweekly surcharge WILL NOT apply. I also acknowledge and certify that it is my responsibility to
notify Human Resources within 10 days if I resume or begin using tobacco products, and as a result, I will be subject to the additional
$75.00 per month/$34.62 bi-weekly tobacco surcharge. Employees certifying that they are non-tobacco users are subject random
tobacco testing throughout the plan year.
I hereby acknowledge and certify that I have completed an approved tobacco-cessation program within the last 10 days;
therefore, making me eligible for the tobacco-free premium discount. (Attach documentation proof of program completion).
The $75.00 per month/$34.62 biweekly tobacco surcharge WILL NOT apply.
I hereby acknowledge and certify that I HAVE USED, tobacco products, in one of the forms identified herein, within the past six
(6) months. The $75.00 per month/$34.62 biweekly tobacco surcharge WILL apply.
Note:
The Columbus Consolidated Government supports its employees’ desire to quit; therefore, the CCG offers two tobacco
cessation programs: 1. Georgia and Alabama Department of Health’s Tobacco Quit Line Program – Telephonic Format.
2. American Cancer Society FreshStart Program – Face-to-Face Onsite Group Setting. The Health & Wellness Center will
also offer tobacco cessation medications.
If your status changes you are obligated to notify Human Resources within ten (10) days.
