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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 Pays 80% 20% 100%
Premium 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.

<15 $233.00 $186.40 $46.60 $233.00

15 $253.72 $202.98 $50.74 $253.72
16 $261.63 $209.30 $52.33 $261.63
17 $269.55 $215.64 $53.91 $269.55
18 $278.08 $222.46 $55.62 $278.08
19 $286.61 $229.29 $57.32 $286.61
20 $295.44 $236.35 $59.09 $295.44
21 $304.58 $243.66 $60.92 $304.58
22 $304.58 $243.66 $60.92 $304.58
23 $304.58 $243.66 $60.92 $304.58
24 $304.58 $243.66 $60.92 $304.58

25 $305.80 $244.64 $61.16 $305.80
26 $311.89 $249.51 $62.38 $311.89
27 $319.20 $255.36 $63.84 $319.20
28 $331.08 $264.86 $66.22 $331.08
29 $340.83 $272.66 $68.17 $340.83
30 $345.70 $276.56 $69.14 $345.70
31 $353.01 $282.41 $70.60 $353.01
32 $360.32 $288.26 $72.06 $360.32
33 $364.89 $291.91 $72.98 $364.89
34 $369.76 $295.81 $73.95 $369.76
35 $372.20 $297.76 $74.44 $372.20
36 $374.63 $299.70 $74.93 $374.63

37 $377.07 $301.66 $75.41 $377.07
38 $379.51 $303.61 $75.90 $379.51
39 $384.38 $307.50 $76.88 $384.38

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