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60 $936.55 $749.24 $187.31 $936.55
61 $969.67 $775.74 $193.93 $969.67
62 $991.41 $793.13 $198.28 $991.41
63 $1,018.68 $814.94 $203.74 $1,018.68
64+ $1,035.24 $828.19 $207.05 $1,035.24

HMO-Advantage Gold 30/50/20%

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

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 $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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