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HMO Advantage Platinum Rate Table

UnitedHealthCare Signature Value Advantage HMO Platinum

HMO-Advantage Angeles
Platinum 20-40/20% Contractor, Inc. You Pay You Pay for Dependent

Monthly Premium Pays 80% 20% 100%
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 $263.99 $211.19 $52.80 $263.99
15 $287.45 $229.96 $57.49 $287.45
16 $296.42 $237.14 $59.28 $296.42
17 $305.40 $244.32 $61.08 $305.40
18 $315.06 $252.05 $63.01 $315.06
19 $324.72 $259.78 $64.94 $324.72
20 $334.73 $267.78 $66.95 $334.73
21 $345.08 $276.06 $69.02 $345.08
22 $345.08 $276.06 $69.02 $345.08
23 $345.08 $276.06 $69.02 $345.08
24 $345.08 $276.06 $69.02 $345.08
25 $346.46 $277.17 $69.29 $346.46
26 $353.36 $282.69 $70.67 $353.36
27 $361.64 $289.31 $72.33 $361.64

28 $375.10 $300.08 $75.02 $375.10
29 $386.14 $308.91 $77.23 $386.14
30 $391.67 $313.34 $78.33 $391.67
31 $399.95 $319.96 $79.99 $399.95
32 $408.23 $326.58 $81.65 $408.23
33 $413.41 $330.73 $82.68 $413.41
34 $418.93 $335.14 $83.79 $418.93
35 $421.69 $337.35 $84.34 $421.69
36 $424.45 $339.56 $84.89 $424.45

37 $427.21 $341.77 $85.44 $427.21
38 $429.97 $343.98 $85.99 $429.97
39 $435.49 $348.39 $87.10 $435.49

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