Page 764 - outbind://23/

HMO Advantage Platinum Rate Table

UnitedHealthCare Signature Value Advantage HMO Platinum

HMO-Advantage Angeles
Platinum 20-40/20% 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.

<15 287.43 229.94 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
22 375.72 300.58 75.14 375.72
23 375.72 300.58 75.14 375.72
24 375.72 300.58 75.14 375.72
25 377.22 301.78 75.44 377.22
26 384.74 307.79 76.95 384.74
27 393.75 315.00 78.75 393.75
28 408.41 326.73 81.68 408.41
29 420.43 336.34 84.09 420.43
30 426.44 341.15 85.29 426.44
31 435.46 348.37 87.09 435.46

32 444.48 355.58 88.90 444.48
33 450.11 360.09 90.02 450.11
34 456.12 364.90 91.22 456.12
35 459.13 367.30 91.83 459.13
36 462.14 369.71 92.43 462.14
37 465.14 372.11 93.03 465.14
38 468.15 374.52 93.63 468.15
39 474.16 379.33 94.83 474.16

3