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Enrollment Fees

Age of Primary Adult Enrollee	+ Number of Dependents [Spouse and/or Child(ren)]	Initial Enrollment Fee	Annual Enrollment Fee	Total Due with Application
Age 18 - 59	0	$25	$98	$123
Age 18 - 59	1	$25	$125	$150
Age 18 - 59	2+	$25	$174	$199
Age 60+	0	$25	$88	$113
Age 60+	1	$25	$112	$137
Age 60+	2+	$25	$158	$183

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The information provided on this site is for general education purposes only and is not intended as a diagnosis, treatment, or a substitute for professional medical or dental advice, diagnosis, or treatment. Consult your dentist or physician for information or treatment specific to you and your health.

FORM 83 v1