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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

HMO‐Advantage Gold 30/50/20%

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

Monthly Premium
Rates Pays 80% 20% 100%
Age
per Month* p e r M o n t h * p e r M o n t h *

*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

3
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