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Declaration of Tobacco Use or
Non-Tobacco Use Form
INFORMATION ABOUT THE TOBACCO PREMIUM PROGRAM
As part of its efforts to support the overall health and wellness of UT
SELECT and UT CONNECT Medical plan members, University of Texas
System has implemented a tobacco premium program surcharge to
discourage the use of tobacco.
Members enrolled in the UT SELECT or UT CONNECT Medical plans will
pay a monthly surcharge in addition to the premium normally charged
for UT SELECT and UT CONNECT Medical plans coverage of $30 per
month if they use tobacco. All members will be required to provide a
declaration regarding their tobacco use as a condition of enrollment
in UT SELECT or UT CONNECT. New members who use tobacco will
begin to pay the additional charge on the first of the month following
enrollment. The Tobacco Premium Program surcharge will be added to
the UT SELECT and UT CONNECT premium that is deducted from your
paycheck. All subscribing members are required to submit a declaration
with regard to themselves and all of their covered dependents
regardless of whether they use tobacco or not.
Premium surcharges are based on three categories: Member $30 per
month; Spouse $30 per month, and Child(ren) $30 per month. The
premium surcharge for a family where any covered dependent child
uses tobacco is $30 regardless of whether other covered dependent
children do not use tobacco. The maximum premium surcharge is $90
per family per month.
Members must declare if they are tobacco users. A “tobacco user”
is defined by as a person who has used tobacco products within the
past sixty (60) days. The sixty days are from the day this declaration
is signed. Members who declare they are non-tobacco users must not
have used tobacco products within the pasty sixty (60) days from the
day this declaration is signed.
All types of tobacco products are included as part of the Tobacco
Premium Program, including, but not limited to: cigarettes, cigars, pipes,
all forms of smokeless tobacco (chewing tobacco, snuff, dip, or any
other product that contains tobacco), clove cigarettes and any other
smoking devices that use tobacco such as hookahs. E-cigarettes, which
contain nicotine, are also included under the tobacco premium program.
More information is available about this program at
www.utsystem.edu/offices/employee-benefits/insurance/
tobacco-premium-program
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