Coverage Start Date
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Date of Birth
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Have you used any form of tobacco in the past 12 months?
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Gender
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Residence Zip Code
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Include a household discount?
*Applies only to approved states
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Please Wait...
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In the following states only non-tobacco rates apply during open enrollment and guaranteed issue periods: AR, CO, IA, IL, KY ,LA, MD, MI, NC, ND, NJ, OH, PA, TN, UT, VA, WI.
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