Page 8 - Polyventive 2022 Benefits Guide
P. 8
Nicotine Use Surcharge
All Employees will be required to provide their
nicotine use status via an aidavit (form) during
annual enrollment. The nicotine surcharge does not
apply to your household. The aidavit should be
signed by you, the employee, only.
If you complete the aidavit stating you use nicotine
products, but enroll in a qualiied cessation program,
you must enroll in the program by December 31,
2021, to avoid the nicotine use surcharge of
an additional 4% contribution per month. (This
surcharge is only applicable if you are enrolled in the
medical and the impact of this additional charge is
relected in the tobacco rates on the previous page.)
A complimentary cessation program is available
through www.aetna.com.
If you falsify information on the nicotine use
aidavit, Polyventive, LLC reserves the right to
impose disciplinary action or charge a penalty.
Spousal Coverage Surcharge
Any Employees who enroll in the Polyventive, LLC
medical plan and choose to enroll their spouse will
be required to sign a spousal coverage aidavit.
You will be required to certify that your spouse does
not have other employer group medical coverage
available. If your spouse does, they are required
to enroll on their employer’s group medical plan
or Polyventive will impose a Spouse Coverage
Surcharge of $200 per month in addition to the
appropriate plan contribution level.
Polyventive reserves the right to impose disciplinary
action or charge a penalty if you falsify information.
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All Employees will be required to provide their
nicotine use status via an aidavit (form) during
annual enrollment. The nicotine surcharge does not
apply to your household. The aidavit should be
signed by you, the employee, only.
If you complete the aidavit stating you use nicotine
products, but enroll in a qualiied cessation program,
you must enroll in the program by December 31,
2021, to avoid the nicotine use surcharge of
an additional 4% contribution per month. (This
surcharge is only applicable if you are enrolled in the
medical and the impact of this additional charge is
relected in the tobacco rates on the previous page.)
A complimentary cessation program is available
through www.aetna.com.
If you falsify information on the nicotine use
aidavit, Polyventive, LLC reserves the right to
impose disciplinary action or charge a penalty.
Spousal Coverage Surcharge
Any Employees who enroll in the Polyventive, LLC
medical plan and choose to enroll their spouse will
be required to sign a spousal coverage aidavit.
You will be required to certify that your spouse does
not have other employer group medical coverage
available. If your spouse does, they are required
to enroll on their employer’s group medical plan
or Polyventive will impose a Spouse Coverage
Surcharge of $200 per month in addition to the
appropriate plan contribution level.
Polyventive reserves the right to impose disciplinary
action or charge a penalty if you falsify information.
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