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HMO Advantage Platinum Rate Table

Continued

UnitedHealthCare Signature Value Advantage HMO Platinum

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

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.

40 $441.01 $352.81 $88.20 $441.01
41 $449.29 $359.43 $89.86 $449.29
42 $457.23 $365.78 $91.45 $457.23
43 $468.27 $374.62 $93.65 $468.27
44 $482.08 $385.66 $96.42 $482.08

45 $498.30 $398.64 $99.66 $498.30
46 $517.62 $414.10 $103.52 $517.62
47 $539.36 $431.49 $107.87 $539.36
48 $564.21 $451.37 $112.84 $564.21
49 $588.71 $470.97 $117.74 $588.71
50 $616.31 $493.05 $123.26 $616.31
51 $643.57 $514.86 $128.71 $643.57
52 $673.60 $538.88 $134.72 $673.60
53 $703.96 $563.17 $140.79 $703.96
54 $736.75 $589.40 $147.35 $736.75
55 $769.53 $615.62 $153.91 $769.53
56 $805.07 $644.06 $161.01 $805.07

57 $840.96 $672.77 $168.19 $840.96
58 $879.26 $703.41 $175.85 $879.26
59 $898.24 $718.59 $179.65 $898.24
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

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