Physician Statement Form (.pdf)
The use of tobacco is one of the leading preventable health risks worldwide. Because UT System is committed to promoting a culture of wellness and disease prevention and also recognizes the costs associated with treating tobacco-related health conditions, members enrolled in the UT SELECT, UT CONNECT, and UT CARE Medical plans pay a monthly surcharge of $30 per month if they use tobacco (in addition to the premium normally charged). All members will be required to provide a declaration regarding their tobacco use as a condition of enrollment in UT SELECT, UT CONNECT, or UT CARE Medical coverage.
What is the TPP and to whom does the TPP apply to?
An out-of-pocket premium of $30 per month for UT SELECT, UT CONNECT, and UT CARE members who use tobacco products. Applies to any tobacco user (age 16 and over) enrolled in the UT SELECT, UT CONNECT, or UT CARE Medical plan.
TPP Premium Rate(s)
|Tobacco User||Monthly Out-of-Pocket Cost|
|Member||$30 per month|
|Spouse||$30 per month|
|Children||$30 per month*|
*The premium for dependent children is $30 per month regardless of how many covered dependent children use tobacco. The maximum premium is $90 per family per month.
Members must declare if they are tobacco users. A "tobacco user" is defined as a person who has used tobacco products within the past sixty (60) days.
Members who declare they are non-tobacco users must not have used tobacco products within the past 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.
How can the UT SELECT, UT CONNECT, or UT CARE Medical plan help me quit using tobacco?
The UT System is committed to helping tobacco users quit by offering our UT SELECT, UT CONNECT, and UT CARE covered members specialized programs at no cost including Smoking/Tobacco Cessation Programs, Pharmaceutical Therapy, and Nicotine Replacement Therapy (NRT) at no cost to the member. Learn more about programs available at our Living Well website.
Exception to Tobacco Use Premium
An exception to the tobacco premium may apply for a tobacco user who has been diagnosed with an uncontrolled health factor and whose physician advises against stopping the use of tobacco. Tobacco users who qualify under this provision should submit a statement from their treating physician in order to waive the tobacco premium. The Physician Statement Form can be submitted anytime during the year to your institution HR/Benefits Office, and the tobacco premium will be waived beginning the first of the month following submission of the form.
Important: A member is responsible to submit a Physician Statement Form every plan year to avoid charges of the Tobacco Premium Program.