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HMO Advantage Platinum Rate Table

Continued

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.

40 480.17 384.14 96.03 480.17
41 489.19 391.35 97.84 489.19
42 497.83 398.26 99.57 497.83
43 509.85 407.88 101.97 509.85
44 524.88 419.90 104.98 524.88
45 542.54 434.03 108.51 542.54
46 563.58 450.86 112.72 563.58
47 587.25 469.80 117.45 587.25
48 614.30 491.44 122.86 614.30

49 640.98 512.78 128.20 640.98
50 671.04 536.83 134.21 671.04
51 700.72 560.58 140.14 700.72
52 733.41 586.73 146.68 733.41
53 766.47 613.18 153.29 766.47
54 802.16 641.73 160.43 802.16
55 837.86 670.29 167.57 837.86
56 876.55 701.24 175.31 876.55
57 915.63 732.50 183.13 915.63
58 957.33 765.86 191.47 957.33
59 978.00 782.40 195.60 978.00
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

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