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ON-LINE CREDIT CARD ENROLLMENT APPLICATION
SELECT "PLAN" FOR QUICK ENROLLMENT
CATASROPHIC ESTIMATED ENROLLMENT
COSTS
| Number of Persons | 1 | 2 | Family | 7+Family(high risk) |
| *Optional Vision | $15 | $30 | $30 | $30 |
| *Optional Dental | $50 | $100 | $100 | $100 |
| *Optional Dental & Vision | $60 | $120 | $120 | $120 |
| Enrollment fee-one time | $45 | $80 | $120 | $120 |
| Drug Plan | $20 | $25 | $30 | $40 |
| Catastrophic Care | $75-120* | $110-160* | $130-200* | $140-210* |
| Health Care Usage | $125 | $180 | $325 | $350 |
| Maintenance Fee | $25 | $30 | $40 | $45 |
| TOTAL: | $245-290 | $345-395 | $525-595 | $575-645 |
NON-CATASTROPHIC ESTIMATED ENROLLMENT COSTS
| Number of Persons | 1 | 2 | Family | 7+Family(high risk) |
| *Optional Vision | $15 | $30 | $30 | $30 |
| *Optional Dental | $50 | $100 | $100 | $100 |
| *Optional Dental & Vision | $60 | $120 | $120 | $120 |
| Enrollment fee-one time | $45 | $80 | $120 | $120 |
| Drug Plan | $20 | $25 | $30 | $40 |
| Health Care Usage | $125 | $180 | $325 | $350 |
| Maintenance Fee | $25 | $30 | $40 | $45 |
| TOTAL: | $170 | $235 | $395 | $435 |
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