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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.

<15 269.87 215.90 53.97 269.87
15 293.86 235.09 58.77 293.86
16 303.03 242.42 60.61 303.03
17 312.20 249.76 62.44 312.20
18 322.08 257.66 64.42 322.08
19 331.96 265.57 66.39 331.96
20 342.19 273.75 68.44 342.19
21 352.77 282.22 70.55 352.77
22 352.77 282.22 70.55 352.77
23 352.77 282.22 70.55 352.77
24 352.77 282.22 70.55 352.77
25 354.18 283.34 70.84 354.18
26 361.24 288.99 72.25 361.24
27 369.70 295.76 73.94 369.70

28 383.46 306.77 76.69 383.46
29 394.75 315.80 78.95 394.75
30 400.39 320.31 80.08 400.39
31 408.86 327.09 81.77 408.86
32 417.33 333.86 83.47 417.33
33 422.62 338.10 84.52 422.62
34 428.26 342.61 85.65 428.26
35 431.08 344.86 86.22 431.08
36 433.91 347.13 86.78 433.91

37 436.73 349.38 87.35 436.73
38 439.55 351.64 87.91 439.55
39 445.20 356.16 89.04 445.20

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