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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 onetime enrollment fee of $10 |
$89 |
Enrollee and one dependent (spouse or child):
plus a onetime enrollment fee of $10 |
$143 |
Enrollee and two or more dependents:
plus a onetime enrollment fee of $10 |
$207 |
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