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HMO Advantage Gold Rate Table

UnitedHealthCare Signature Value Advantage HMO Gold

HMO-Advantage Angeles You Pay You Pay for Dependent
Gold 30-60/1000 Contractor, Inc.

Monthly
Premium Rates Pays 80% 20% 100%
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.

<15 260.00 208.00 52.00 260.00
15 283.11 226.49 56.62 283.11
16 291.95 233.56 58.39 291.95
17 300.78 240.62 60.16 300.78
18 310.30 248.24 62.06 310.30
19 319.82 255.86 63.96 319.82
20 329.67 263.74 65.93 329.67
21 339.87 271.90 67.97 339.87
22 339.87 271.90 67.97 339.87
23 339.87 271.90 67.97 339.87

24 339.87 271.90 67.97 339.87
25 341.23 272.98 68.25 341.23
26 348.03 278.42 69.61 348.03
27 356.18 284.94 71.24 356.18
28 369.44 295.55 73.89 369.44
29 380.31 304.25 76.06 380.31
30 385.75 308.60 77.15 385.75
31 393.91 315.13 78.78 393.91
32 402.07 321.66 80.41 402.07

33 407.16 325.73 81.43 407.16
34 412.60 330.08 82.52 412.60
35 415.32 332.26 83.06 415.32
36 418.04 334.43 83.61 418.04
37 420.76 336.61 84.15 420.76
38 423.48 338.78 84.70 423.48
39 428.92 343.14 85.78 428.92

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