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HMO Advantage Gold Rate Table

Continued

HMO-Advantage Gold 30-50/30%

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

Monthly Premium
Pays 80% 20% 100%
Age Rates

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 $395.50 $316.40 $79.10 $395.50

44 $407.16 $325.73 $81.43 $407.16
45 $420.85 $336.68 $84.17 $420.85
46 $437.18 $349.74 $87.44 $437.18
47 $455.54 $364.43 $91.11 $455.54
48 $476.52 $381.22 $95.30 $476.52
49 $497.21 $397.77 $99.44 $497.21
50 $520.53 $416.42 $104.11 $520.53
51 $543.55 $434.84 $108.71 $543.55
52 $568.91 $455.13 $113.78 $568.91

53 $594.56 $475.65 $118.91 $594.56
54 $622.25 $497.80 $124.45 $622.25
55 $649.93 $519.94 $129.99 $649.93
56 $679.95 $543.96 $135.99 $679.95
57 $710.26 $568.21 $142.05 $710.26
58 $742.61 $594.09 $148.52 $742.61
59 $758.64 $606.91 $151.73 $758.64
60 $791.00 $632.80 $158.20 $791.00
61 $818.97 $655.18 $163.79 $818.97
62 $837.34 $669.87 $167.47 $837.34
63 $860.36 $688.29 $172.07 $860.36
64+ $874.35 $699.48 $174.87 $874.35

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