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Y be defaulted to the base rate and will not be able to participate in the non tobacco use discount for the plan year. COVERAGE LEVELS: Member Only Member and Spouse Only Member and Child(ren) Only Member and Family (Spouse AND Child(ren)) RELATIONSHIP CODES: SP spouse D daughter P stepson or stepdaughter S son GC grandson or granddaughter L legal custody dependent XX qualified medical child support order H totally disabled child over age 26 I have read and agree to the.

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