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| HOW MUCH DO I PAY? |
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| The annual Premium for the Initial Contract Term is: |
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Enrollee only (one person):
plus a one-time enrollment fee of $10.00 |
$87.36 |
Enrollee and one dependent (spouse or child):
plus a one-time enrollment fee of $10.00 |
$144.12 |
Enrollee and two or more dependents:
plus a one-time enrollment fee of $10.00 |
$213.12 |
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