Page 444 - outbind://23/

HMO Advantage Gold Rate Table

Continued

UnitedHealthCare Signature Value Advantage HMO Gold

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

40 396.13 $316.90 $79.23 $396.13
41 403.57 $322.86 $80.71 $403.57
42 410.70 $328.56 $82.14 $410.70
43 420.62 $336.50 $84.12 $420.62
44 433.01 $346.41 $86.60 $433.01
45 447.58 $358.06 $89.52 $447.58
46 464.94 $371.95 $92.99 $464.94
47 484.47 $387.58 $96.89 $484.47
48 506.78 $405.42 $101.36 $506.78
49 528.79 $423.03 $105.76 $528.79
50 553.59 $442.87 $110.72 $553.59

51 578.08 $462.46 $115.62 $578.08
52 605.04 $484.03 $121.01 $605.04
53 632.32 $505.86 $126.46 $632.32
54 661.76 $529.41 $132.35 $661.76
55 691.21 $552.97 $138.24 $691.21
56 723.14 $578.51 $144.63 $723.14
57 755.37 $604.30 $151.07 $755.37
58 789.78 $631.82 $157.96 $789.78
59 806.83 $645.46 $161.37 $806.83

60 841.23 $672.98 $168.25 $841.23
61 870.99 $696.79 $174.20 $870.99
62 890.52 $712.42 $178.10 $890.52
63 915.00 $732.00 $183.00 $915.00
64+ 929.88 $743.90 $185.98 $929.88

6