Page 385 - outbind://23/

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 Pays 80% 20% 100%
Age Premium 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.

40 $389.25 $311.40 $77.85 $389.25
41 $396.56 $317.25 $79.31 $396.56
42 $403.57 $322.86 $80.71 $403.57

43 $413.32 $330.66 $82.66 $413.32
44 $425.50 $340.40 $85.10 $425.50
45 $439.81 $351.85 $87.96 $439.81
46 $456.87 $365.50 $91.37 $456.87
47 $476.06 $380.85 $95.21 $476.06
48 $497.99 $398.39 $99.60 $497.99
49 $519.61 $415.69 $103.92 $519.61
50 $543.98 $435.18 $108.80 $543.98
51 $568.04 $454.43 $113.61 $568.04

52 $594.54 $475.63 $118.91 $594.54
53 $621.34 $497.07 $124.27 $621.34
54 $650.28 $520.22 $130.06 $650.28
55 $679.21 $543.37 $135.84 $679.21
56 $710.59 $568.47 $142.12 $710.59
57 $742.26 $593.81 $148.45 $742.26
58 $776.07 $620.86 $155.21 $776.07
59 $792.82 $634.26 $158.56 $792.82
60 $826.63 $661.30 $165.33 $826.63
61 $855.87 $684.70 $171.17 $855.87
62 $875.06 $700.05 $175.01 $875.06
63 $899.12 $719.30 $179.82 $899.12

64+ $913.74 $730.99 $182.75 $913.74

6