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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.

40 450.84 360.67 90.17 450.84
41 459.31 367.45 91.86 459.31
42 467.42 373.94 93.48 467.42
43 478.71 382.97 95.74 478.71
44 492.82 394.26 98.56 492.82

45 509.40 407.52 101.88 509.40
46 529.16 423.33 105.83 529.16
47 551.38 441.10 110.28 551.38
48 576.78 461.42 115.36 576.78
49 601.83 481.46 120.37 601.83
50 630.05 504.04 126.01 630.05
51 657.92 526.34 131.58 657.92
52 688.61 550.89 137.72 688.61
53 719.65 575.72 143.93 719.65
54 753.16 602.53 150.63 753.16
55 786.68 629.34 157.34 786.68
56 823.01 658.41 164.60 823.01

57 859.70 687.76 171.94 859.70
58 898.86 719.09 179.77 898.86
59 918.26 734.61 183.65 918.26
60 957.42 765.94 191.48 957.42
61 991.28 793.02 198.26 991.28
62 1013.51 810.81 202.70 1013.51
63 1041.38 833.10 208.28 1041.38
64+ 1058.31 846.65 211.66 1058.31

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