Home > Divisions/Offices > State Health Benefit Plan (SHBP) > Additional Health Plan Information > Tobacco Surcharges Policies and Instructions

Tobacco Surcharges Policies and Instructions

Note: members that failed to answer the surcharge questions, should refer to the Non-Tobacco user Policy and Affidavit

Active Members

Cigna Tobacco Cessation Flyer              UHC Tobacco Cessation Flyer

2012

• 2012 Active Employee Tobacco Cessation Policy
• 2012 Active Employee Tobacco Cessation Affidavit
• 2012 Active Employee Non-Tobacco Users Policy
• 2012 Active Employee Non-Tobacco User Affidavit

2011

• 2011 Active Employee Non-Tobacco User Policy
• 2011 Active Employee Non-Tobacco User Affidavit
• 2011 Active Employee Tobacco Cessation Policy
• 2011 Active Employee Tobacco Cessation Affidavit

Retirees

2012

• 2012 Retiree Tobacco Cessation Policy
• 2012 Retiree Non-Tobacco User Affidavit
• 2012 Retiree Non-Tobacco User Policy
• 2012 Retiree Tobacco Cessation Affidavit

2011

• 2011 Retiree Non-Tobacco User Affidavit
• 2011 Retiree Non-Tobacco Cessation Policy
• 2011 Retiree Non-Tobacco User Policy
• 2011 Retiree Tobacco Cessation Affidavit

Instructions for Health and Wellness Programs

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2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

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2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

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2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

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2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->

---

2010 Non-Tobacco Use

 Non-Tobacco Users Policy - Updated 11/12/09
 Non-Tobacco Users Affidavit Form - Updated 11/12/09

To view PDF documents you will need the free Acrobat Reader application.

-->