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TOBACCO CESSATION REIMBURSEMENT <br />FOR CITY OF ELK RIVER & ELK RIVER MUNICIPAL UTILITIES EMPLOYEES <br />Although there are many free resources available to help people stop using tobacco, we <br />recognize the benefits of tobacco cessation and wish to help employees accomplish this goal. <br />Using funds received from the BlueCross BlueShield tobacco settlement, employees who <br />choose to quit using tobacco may be reimbursed up to $100.00 for tobacco cessation aids. <br />These aids include nicotine replacement therapy {ie: patches, gum, lozenges), prescription co- <br />pays, fees for hypnosis or acupuncture, and fees for group or individual classes through an <br />approved program. (Classes must be approved for reimbursement prior to enrolling.) <br />Over-the-counter nicotine replacement therapies are covered by the City's and Utilities' <br />prescription drug plans with a written prescription from your doctor. Call your doctor to get a <br />prescription, take the prescription to your pharmacy, and all you'll pay is the co-pay. You can <br />be reimbursed for the co-pay out of the $100 that is available to you through the tobacco <br />cessation reimbursement program. (Paying only the co-pay instead of the full cost of over-the- <br />counter items will make the $100 available to you to go further...) <br />Additionally, the City's and Utilities' health plans offer free support to members. Call Blue Print <br />for Health Stop Smoking Program at 1-888-662-2583. <br />Good luck and great success! <br />To receive reimbursement you must bean employee of the City of Elk River or Elk River <br />Municipal Utilities, complete this reimbursement form, attach your receipts, and submit your <br />request to: <br />City of Elk River employees: Lauren Wipper, Human Resource Representative <br />Elk River Municipal Utilities employees: Theresa Slominski, Finance Director <br />Prior Approval for Group or Individual Class: <br />Lauren Wipper or Theresa Slominski Signature Date <br />Name: <br />Address: <br />Tobacco Cessation Aid Purchased: <br />Amount of Reimbursement Requested: <br />I acknowledge and agree that all items included in this reimbursement request will be/were <br />used by me for the purpose of tobacco cessation. <br />Employee Signature Date <br />