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HMO Advantage Gold Rate Table

Continued

UnitedHealthCare Signature Value Advantage HMO Gold

HMO-Advantage Angeles
Gold 30-60/1000 Contractor, Inc. You Pay You Pay for Dependent

Monthly Pays 80% 20% 100%
Age Premium Rates

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.

40 454.07 363.26 90.81 454.07
41 462.60 370.08 92.52 462.60
42 470.77 376.62 94.15 470.77
43 482.14 385.71 96.43 482.14
44 496.35 397.08 99.27 496.35

45 513.05 410.44 102.61 513.05
46 532.95 426.36 106.59 532.95
47 555.33 444.26 111.07 555.33
48 580.92 464.74 116.18 580.92
49 606.14 484.91 121.23 606.14
50 634.57 507.66 126.91 634.57
51 662.63 530.10 132.53 662.63
52 696.35 554.84 138.71 696.35
53 724.81 579.85 144.96 724.81
54 758.57 606.86 151.71 758.57
55 792.32 633.86 158.46 792.32
56 828.91 663.13 165.78 828.91

57 865.87 692.70 173.17 865.87
58 905.30 724.24 181.06 905.30
59 924.85 739.88 184.97 924.85
60 964.28 771.42 192.86 964.28
61 998.39 798.71 199.68 998.39
62 1020.78 816.62 204.16 1020.78
63 1048.85 839.08 209.77 1048.85
64+ 1065.90 852.72 213.18 1065.90

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