Copayment A - Family Size 2
Monthly Income revised amountsMonthly Copayment
$ 0 - 517 $ 2.00
518 - 647 3.00
648 - 776 9.00
777 - 905 16.00
906 - 1034 25.00
1035 - 1164 35.00
1165 - 1293 47.00
1294 - 1422 61.00
1423 - 1551 77.00
1552 - 1681 94.00
1682 - 1810 113.00
1811 - 1939 134.00
1940 - 2068 156.00
2069 - 2198 180.00
2199 - 2327 206.00
2328 - 2392 224.00
Copayment A - Family Size 3
Monthly Income revised amountsMonthly Copayment
$ 0 - 651 $ 2.00
652 - 814 3.00
815 - 977 12.00
978 - 1140 20.00
1141 - 1302 31.00
1303 - 1465 44.00
1466 - 1628 60.00
1629 - 1791 77.00
1792 - 1953 97.00
1954 - 2116 119.00
2117 - 2279 143.00
2280 - 2442 169.00
2443 - 2604 197.00
2605 - 2767 227.00
2768 - 2930 260.00
2931 - 3011 283.00
Copayment A - Family Size 4
Monthly Income revised amountsMonthly Copayment
$ 0 - 785 $ 2.00
786 - 982 3.00
983 - 1178 15.00
1179 - 1374 24.00
1375 - 1570 37.00
1571 - 1767 54.00
1768 - 1963 72.00
1964 - 2159 93.00
2160 - 2355 117.00
2356 - 2552 143.00
2553 - 2748 172.00
2749 - 2944 204.00
2945 - 3140 238.00
3141 - 3337 274.00
3338 - 3533 314.00
3534 - 3631 341.00
Copayment A - Family Size 5
revised textMonthly Income Monthly Copayment
$ 0 - 919 $ 2.00
920 - 1149 3.00
1150 - 1379 18.00
1380 - 1609 29.00
1610 - 1838 44.00
1839 - 2068 62.00
2069 - 2298 84.00
2299 - 2528 109.00
2529 - 2757 137.00
2758 - 2987 168.00
2988 - 3217 202.00
3218 - 3447 239.00
3448 - 3676 279.00
3677 - 3906 322.00
3907 - 4136 368.00
4137 - 4251 400.00
Copayment A - Family Size 6
Monthly Income revised textMonthly Copayment
$ 0 - 1053 $2.00
1054 - 1317 3.00
1318 - 1580 20.00
1581 - 1843 32.00
1844 - 2106 50.00
2107 - 2370 72.00
2371 - 2633 97.00
2634 - 2896 125.00
2897 - 3159 157.00
3160 - 3423 193.00
3424 - 3686 231.00
3687 - 3949 273.00
3950 - 4212 319.00
4213 - 4476 369.00
4477 - 4739 421.00
4740 - 4871 458.00
Copayment A - Family Size 7
Monthly Income revised textMonthly Copayment
$ 0 - 1187 $ 2.00
1188 - 1484 3.00
1485 - 1781 23.00
1782 - 2078 36.00
2079 - 2374 57.00
2375 - 2671 81.00
2672 - 2968 109.00
2969 - 3265 141.00
3266 - 3561 177.00
3562 - 3858 217.00
3859 - 4155 261.00
4156 - 4452 308.00
4453 - 4748 360.00
4749 - 5045 416.00
5046 - 5342 475.00
5343 - 5490 517.00
Copayment A - Family Size 8
Monthly Income revised textMonthly Copayment
$ 0 - 1321 $ 2.00
1322 - 1652 3.00
1653 - 1982 25.00
1983 - 2312 41.00
2313 - 2642 63.00
2643 - 2973 90.00
2974 - 3303 122.00
3304 - 3633 157.00
3634 - 3963 197.00
3964 - 4294 242.00
4295 - 4624 290.00
4625 - 4954 344.00
4955 - 5284 401.00
5285 - 5615 463.00
5616 - 5945 529.00
5946 - 6110 575.00
Copayment A - Family Size 9
Monthly Income revised textMonthly Copayment
$ 0 - 1455 $ 2.00
1456 - 1819 3.00
1820 - 2183 27.00
2184 - 2547 45.00
2548 - 2910 69.00
2911 - 3274 107.00
3275 - 3638 99.00
3639 - 4002 173.00
4003 - 4365 217.00
4366 - 4729 266.00
4730 - 5093  320.00
5094 - 5457 378.00
5458 - 5820 442.00
5821 - 6184 509.00
6185 - 6548 582.00
6549 - 6730 634.00
Copayment A - Family Size 10
Monthly Income revised textMonthly Copayment
$ 0 - 1589 $ 2.00
1590 - 1987 3.00
1988 - 2384 30.00
2385 - 2781 49.00
2782 - 3178 76.00
3179 - 3576 109.00
3577 - 3973 146.00
3974 - 4370 189.00
4371 - 4767 237.00
4768 - 5165 291.00
5166 - 5562 350.00
5563 - 5959 413.00
5960 - 6356 482.00
6357 - 6754 557.00
6755 - 7151 637.00
7152 - 7350 692.00