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HMO Advantage Gold Rate Table

HMO-Advantage Gold 30-50/30%

HMO-Advantage Angeles You Pay You Pay for Dependent
Gold 30-50/30% Contractor, Inc.

Monthly Premium
Rates Pays 80% 20% 100%
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.

0-20 $185.07 $148.06 $37.01 $185.07
21 $291.45 $233.16 $58.29 $291.45
22 $291.45 $233.16 $58.29 $291.45
23 $291.45 $233.16 $58.29 $291.45

24 $291.45 $233.16 $58.29 $291.45
25 $292.62 $234.10 $58.52 $292.62
26 $298.44 $238.75 $59.69 $298.44
27 $305.44 $244.35 $61.09 $305.44
28 $316.81 $253.45 $63.36 $316.81
29 $326.13 $260.90 $65.23 $326.13
30 $330.80 $264.64 $66.16 $330.80
31 $337.79 $270.23 $67.56 $337.79
32 $344.79 $275.83 $68.96 $344.79
33 $349.16 $279.33 $69.83 $349.16
34 $353.82 $283.06 $70.76 $353.82
35 $356.15 $284.92 $71.23 $356.15

36 $358.48 $286.78 $71.70 $358.48
37 $360.82 $288.66 $72.16 $360.82
38 $363.15 $290.52 $72.63 $363.15
39 $367.81 $294.25 $73.56 $367.81
40 $372.47 $297.98 $74.49 $372.47
41 $379.47 $303.58 $75.89 $379.47
42 $386.17 $308.94 $77.23 $386.17

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