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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

HMO-Advantage Gold 30/50/20%

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

Monthly Premium
Rates Pays 80% 20% 100%
Age
per Month* p e r M o n t h * p e r M o n t h *

*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

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