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60 1019.70 815.76 203.94 1019.70
61 1055.77 844.62 211.15 1055.77
62 1079.44 863.55 215.89 1079.44
63 1109.13 887.30 221.83 1109.13
64+ 1127.16 901.73 225.43 1127.16

HMO-Advantage Gold 30/70/800d

HMO-Advantage
Gold 30-70/800d Angeles 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.

<15 271.80 217.44 54.36 271.80
15 295.96 236.77 59.19 295.96

16 305.20 244.16 61.04 305.20
17 314.44 251.55 62.89 314.44
18 324.39 259.51 64.88 324.39
19 334.44 267.47 66.87 334.44
20 324.39 275.71 68.93 324.39
21 355.30 284.24 71.06 355.30
22 355.30 284.24 71.06 355.30
23 355.30 284.24 71.06 355.30
24 355.30 284.24 71.06 355.30
25 356.72 285.38 71.34 356.72
26 363.83 291.06 72.77 363.83
27 372.35 297.88 74.47 372.35

28 386.21 308.97 77.24 386.21
29 397.58 318.06 79.52 397.58
30 403.27 322.62 80.65 403.27
31 411.79 329.43 82.36 411.79

3
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