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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.

<15 $260.56 $208.45 $52.11 $260.56
15 $283.72 $226.98 $56.74 $283.72
16 $292.58 $234.06 $58.52 $292.58
17 $301.43 $241.14 $60.29 $301.43
18 $310.97 $248.78 $62.19 $310.97

19 $320.50 $256.40 $64.10 $320.50
20 $330.38 $264.30 $66.08 $330.38
21 $340.60 $272.48 $68.12 $340.60
22 $340.60 $272.48 $68.12 $340.60
23 $340.60 $272.48 $68.12 $340.60
24 $340.60 $272.48 $68.12 $340.60
25 $341.96 $273.57 $68.39 $341.96
26 $348.77 $279.02 $69.75 $348.77
27 $356.95 $285.56 $71.39 $356.95

28 $370.23 $296.18 $74.05 $370.23
29 $381.13 $304.90 $76.23 $381.13
30 $386.58 $309.26 $77.32 $386.58
31 $394.76 $315.81 $78.95 $394.76
32 $402.93 $322.34 $80.59 $402.93
33 $408.04 $326.43 $81.61 $408.04
34 $413.49 $330.79 $82.70 $413.49
35 $416.21 $332.97 $83.24 $416.21
36 $418.94 $335.15 $83.79 $418.94
37 $421.66 $337.33 $84.33 $421.66
38 $424.39 $339.51 $84.88 $424.39
39 $429.84 $343.87 $85.97 $429.84

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