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HMO Advantage Gold Rate Table

UnitedHealthCare Signature Value Advantage HMO Gold

HMO-Advantage
Gold 30- Angeles You Pay You Pay for Dependent
60/20%/250 Contractor, Inc.

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.

<15 237.12 $189.70 $47.42 $237.12
15 258.20 $206.56 $51.64 $258.20
16 266.26 $213.01 $53.25 $266.26
17 274.31 $219.45 $54.86 $274.31
18 282.99 $226.39 $56.60 $282.99
19 291.67 $233.34 $58.33 $291.67
20 300.66 $240.53 $60.13 $300.66
21 309.96 $247.97 $61.99 $309.96
22 309.96 $247.97 $61.99 $309.96
23 309.96 $247.97 $61.99 $309.96

24 309.96 $247.97 $61.99 $309.96
25 311.20 $248.96 $62.24 $311.20
26 317.40 $253.92 $63.48 $317.40
27 324.84 $259.87 $64.97 $324.84
28 336.93 $269.54 $67.39 $336.93
29 346.85 $277.48 $69.37 $346.85
30 351.80 $281.44 $70.36 $351.80
31 359.24 $287.39 $71.85 $359.24
32 366.68 $293.34 $73.34 $366.68

33 371.33 $297.06 $74.27 $371.33
34 376.29 $301.03 $75.26 $376.29
35 378.77 $303.02 $75.75 $378.77
36 381.25 $305.00 $76.25 $381.25
37 383.73 $306.98 $76.75 $383.73
38 386.21 $308.97 $77.24 $386.21
39 391.17 $312.94 $78.23 $391.17

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