Page 383 - outbind://23/

HMO Advantage Platinum Rate Table

Continued

HMO-Advantage Platinum 20-40/30%

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

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.

40 $435.29 $348.23 $87.06 $435.29
41 $443.46 $354.77 $88.69 $443.46

42 $451.30 $361.04 $90.26 $451.30
43 $462.19 $369.75 $92.44 $462.19
44 $475.82 $380.66 $95.16 $475.82
45 $491.83 $393.46 $98.37 $491.83
46 $510.90 $408.72 $102.18 $510.90
47 $532.36 $425.89 $106.47 $532.36
48 $556.88 $445.50 $111.38 $556.88
49 $581.06 $464.85 $116.21 $581.06
50 $608.31 $486.65 $121.66 $608.31
51 $635.22 $508.18 $127.04 $635.22

52 $664.85 $531.88 $132.97 $664.85
53 $694.82 $555.86 $138.96 $694.82
54 $727.18 $581.74 $145.44 $727.18
55 $759.54 $607.63 $151.91 $759.54
56 $794.62 $635.70 $158.92 $794.62
57 $830.04 $664.03 $166.01 $830.04
58 $867.85 $694.28 $173.57 $867.85
59 $886.58 $709.26 $177.32 $886.58
60 $924.39 $739.51 $184.88 $924.39
61 $957.09 $765.67 $191.42 $957.09
62 $978.54 $782.83 $195.71 $978.54
63 $1,005.45 $804.36 $201.09 $1,005.45

64+ $1,021.80 $817.44 $204.36 $1,021.80

4