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ANGELES CONTRACTOR, INC.(ACI)

OPEN ENROLLMENT OVERVIEW

AND SUMMARY

2021 SUMMARY OF EMPLOYEE BENEFITS CHANGES

Angeles Contractor, Inc. will renew our employee benefit Medical Plan with no changes in plan. However, current
plan benefit will be slightly changed with renewal plan from 08/01/2021. Please review “Plan change highlights”.
HMO 1 UHC HMO Advantage Platinum Plan Benefit Changes 20-40/20% (CE-NV)

HMO 2 UHC HMO Advantage Gold Plan Benefit Changes 30-70/800d (CE-NW)
The following employee contributions will become effect on 08/01/2020, and will be reflected on your July paycheck.

HMO-Advantage Platinum 20-40/20%

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

Monthly Premium
Age Rates Pays 80% 20% 100%

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.

<15 287.43 229.94 57.49 287.43
15 312.97 250.38 62.59 312.97
16 322.74 258.19 64.55 322.74
17 332.51 266.01 66.50 332.51
18 343.03 274.42 68.61 343.03
19 353.55 282.84 70.71 353.55
20 364.45 291.56 72.89 364.45
21 375.72 300.58 75.14 375.72