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HMO Advantage Platinum Rate Table

Continued

HMO-Advantage Platinum 20-40/30%
HMO-Advantage
Angeles
Platinum 20- Contractor, Inc. You Pay You Pay for Dependent
40/30%
Monthly Premium Pays 80% 20% 100%
Rates
Age
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.

43 $440.40 $352.32 $88.08 $440.40

44 $453.38 $362.70 $90.68 $453.38
45 $468.64 $374.91 $93.73 $468.64
46 $486.81 $389.45 $97.36 $486.81
47 $507.26 $405.81 $101.45 $507.26
48 $530.62 $424.50 $106.12 $530.62
49 $553.67 $442.94 $110.73 $553.67
50 $579.63 $463.70 $115.93 $579.63
51 $605.27 $484.22 $121.05 $605.27
52 $633.50 $506.80 $126.70 $633.50
53 $662.06 $529.65 $132.41 $662.06
54 $692.89 $554.31 $138.58 $692.89

55 $723.72 $578.98 $144.74 $723.72
56 $757.15 $605.72 $151.43 $757.15
57 $790.90 $632.72 $158.18 $790.90
58 $826.93 $661.54 $165.39 $826.93
59 $844.78 $675.82 $168.96 $844.78
60 $880.80 $704.64 $176.16 $880.80
61 $911.96 $729.57 $182.39 $911.96
62 $932.40 $745.92 $186.48 $932.40
63 $958.04 $766.43 $191.61 $958.04
64+ $973.62 $778.90 $194.72 $973.62

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