Copayment A - Family Size 2
Revised TextMonthly Income revised amountsMonthly Copayment
$ 0 -  525 $ 2.00
526   - 656 3.00
657  -  787 9.00
788   -  918 16.00
919   - 1049 23.00
1050 - 1180 33.00
1181 - 1311 45.00
1312 - 1442 57.00
1443 - 1573 73.00
1574 - 1705 88.00
1706 - 1836 107.00
1837 - 1967 126.00
1968 - 2098 146.00
2099 - 2229 168.00
2230 - 2360 192.00
2361 - 2426 212.00
Copayment A - Family Size 3
Revised TextMonthly Income revised amountsMonthly Copayment
$ 0 - 660 $ 2.00
661 - 825 3.00
826 - 990 12.00
991 - 1155 20.00
1156 - 1320 29.00
1321 - 1485 42.00
1486 - 1650 56.00
1651 - 1815 73.00
1816 - 1979 91.00
1980 - 2144 111.00
2145 - 2309 135.00
2310 - 2474 159.00
2475 - 2639 185.00
2640 - 2804 213.00
2805 - 2969 244.00
2970 - 3051 267.00
Copayment A - Family Size 4
Monthly Income revised amountsMonthly Copayment
$ 0 - 795 $ 2.00
796 - 994 3.00
995 - 1193 15.00
1194 - 1392 22.00
1393 - 1590 35.00
1591 - 1789 50.00
1790 - 1988 68.00
1989 - 2187 87.00
2188 - 2385 109.00
2386 - 2584 135.00
2585 - 2783 162.00
2784 - 2982 192.00
2983 - 3180 222.00
3181 - 3379 256.00
3380 - 3578 294.00
3579 - 3677 321.00
Copayment A - Family Size 5
revised textMonthly Income Revised TextMonthly Copayment
$ 0 - 931 $ 2.00
932 - 1163 3.00
1164 - 1396 16.00
1397- 1629 27.00
1630 - 1861 42.00
1862 - 2094 58.00
2095 - 2326 80.00
2327 - 2559 103.00
2560 - 2791 129.00
2792 - 3024 158.00
3025 - 3257 190.00
3258 - 3489 223.00
3490 - 3722 261.00
3723- 3954 302.00
3955 - 4187 344.00
4188 - 4303 376.00
Copayment A - Family Size 6
Revised TextMonthly Income revised textMonthly Copayment
$ 0 - 1066 $2.00
1067 - 1333 3.00
1334 - 1599 18.00
1600 - 1865 30.00
1866 - 2132 48.00
2133 - 2398 68.00
2399 - 2665 91.00
2666 - 2931 117.00
2932 - 3197 147.00
3198 - 3464 181.00
3465 - 3730 217.00
3731 - 3997 255.00
3998 - 4263 299.00
4264 - 4530 345.00
4531 - 4796 393.00
4797 - 4929 432.00
Copayment A - Family Size 7
Revised TextMonthly Income revised textMonthly Copayment
$ 0 - 1201 $ 2.00
1202 - 1502 3.00
1503 - 1802 21.00
1803 - 2102 34.00
2103 - 2402 53.00
2403 - 2703 77.00
2704 - 3003 103.00
3004 - 3303 133.00
3304 - 3603 167.00
3604 - 3904 203.00
3905 - 4204 245.00
4205 - 4504 288.00
4505 - 4804 336.00
4805 - 5105 388.00
5106 - 5405 443.00
5406 - 5555 487.00
Copayment A - Family Size 8
Revised TextMonthly Income revised textMonthly Copayment
$ 0 - 1337 $ 2.00
1338 - 1671 3.00
1672 - 2005 23.00
2006 - 2339 39.00
2340 - 2673 59.00
2674 - 3007 84.00
3008 - 3341 114.00
3342 - 3675 147.00
3676 - 4009 185.00
4010 - 4344 226.00
4345 - 4678 272.00
4679 - 5012 322.00
5013 - 5346 375.00
5347 - 5680 433.00
5681 - 6014 495.00
6015 - 6181 541.00
Copayment A - Family Size 9
Revised TextMonthly Income revised textMonthly Copayment
$ 0 - 1472 $ 2.00
1473 - 1840 3.00
1841 - 2208 25.00
2209 - 2576 43.00
2577 - 2944 65.00
2945 - 3312 93.00
3313 - 3680 126.00
3681 - 4048 163.00
4049 - 4415 203.00
4416 - 4783 250.00
4784 - 5151  300.00
5152 - 5519 354.00
5520 - 5887 414.00
5888 - 6255 475.00
6256 - 6623 544.00
6624 - 6807 596.00
Copayment A - Family Size 10
Revised TextMonthly Income revised textMonthly Copayment
$ 0 - 1607 $ 2.00
1608 - 2009 3.00
2010 - 2411 28.00
2412 - 2813 47.00
2814 - 3214 72.00
3215 - 3616 103.00
3617 - 4018 138.00
4019 - 4420 177.00
4421 - 4821 223.00
4822 - 5223 273.00
5224 - 5625 328.00
5626 - 6027 387.00
6028 - 6428 450.00
6429 - 6830 521.00
6831 - 7232 595.00
7233 - 7433 652.00