Tobacco Use Certification

If an emloyee elects coverage under one of the state health care plans and uses a tobacco product, an employee will be charged a $40 monthly surcharge.

If the employee has a dependent spouse /child(ren) listed on the state health plan and that dependent uses a tobacco product, the surcharge will be $60 per month.

All employees must certify that no one covered under his or her health insurance plan uses tobacco products, and that no one has used the product during the past six months by completing a Certification Regarding Tobacco Use form.

If you have not certified or need to change your certification, go to the Public Employee Benefits Authority (PEBA) Insurance Benefits website which is and click on Insurance Benefits, Forms, Health Insurance, and then Certification Regarding Tobacco Use tabs to locate the Tobacco Use form.   

Complete the Certification Regarding Tobacco Use form as follows:
-Write/type the employee's name and social security number on the subscriber name and BIN/SSN line.
-Mark the appropriate boxes (Non-tobacco user premium or Tobacco user premium)
-The employee will sign the form on the subscriber's signature line and then date the form.

Return the form to the Benefits Administrator for signature and then the form will be sent to PEBA Insurance Company for processing. The certification will be effective the first of the month after PEBA Insurance Company receives the form.

You will be automatically charged the tobacco-user premium, unless you complete the Certification Regarding Tobacco Use form.   

State Health Plan and BlueChoice HealthPlan subscribers and their covered dependents can participate in the Tobacco Cessation Program by calling 866-784-8454.

A subscriber and his covered dependents can apply for the non-tobacco-user premium after being tobacco free for six months, by completing the Certification Regarding Tobacco Use form.

For more information, please call PEBA Insurance Benefits Customer Service at 888-260-9430.