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HMO Advantage Platinum Rate Table

HMO-Advantage Platinum 20-40/30%

HMO-Advantage Angeles You Pay You Pay for Dependent
Platinum 20-40/30% Contractor, Inc.

Monthly Premium
Age Rates Pays 80% 20% 100%

per Month* per Month* per Month*

*If you enroll with your spouse and/or children, you must pay the full
premium for your spouse and/or children in addition to your cost of share
below.

0-20 $206.08 $164.86 $41.22 $206.08
21 $324.54 $259.63 $64.91 $324.54
22 $324.54 $259.63 $64.91 $324.54
23 $324.54 $259.63 $64.91 $324.54
24 $324.54 $259.63 $64.91 $324.54
25 $325.84 $260.67 $65.17 $325.84
26 $332.33 $265.86 $66.47 $332.33
27 $340.12 $272.10 $68.02 $340.12
28 $352.77 $282.22 $70.55 $352.77

29 $363.16 $290.53 $72.63 $363.16
30 $368.35 $294.68 $73.67 $368.35
31 $376.14 $300.91 $75.23 $376.14
32 $383.93 $307.14 $76.79 $383.93
33 $388.80 $311.04 $77.76 $388.80
34 $393.99 $315.19 $78.80 $393.99
35 $396.59 $317.27 $79.32 $396.59
36 $399.18 $319.34 $79.84 $399.18
37 $401.78 $321.42 $80.36 $401.78
38 $404.38 $323.50 $80.88 $404.38
39 $409.57 $327.66 $81.91 $409.57
40 $414.76 $331.81 $82.95 $414.76

41 $422.55 $338.04 $84.51 $422.55
42 $430.02 $344.02 $86.00 $430.02

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