Copayment A - Family Size 2
revised textMonthly Income revised amountsMonthly Copayment
$ 0 - 505 $ 2.00
506 - 631 3.00
632 - 757 10.00
758 - 883 17.00
884 - 1009 26.00
1010 - 1135 37.00
1136 - 1261 50.00
1262 - 1387 65.00
1388 - 1513 82.00
1514 - 1640 100.00
1641 - 1766 120.00
1767 - 1892 142.00
1893 - 2018 166.00
2019 - 2144 192.00
2145 - 2270 219.00
2271 - 2333 237.00
Copayment A - Family Size 3
revised textMonthly Income revised amountsMonthly Copayment
$ 0 - 637 $ 2.00
638 - 796 3.00
797 - 955 13.00
956 - 1114 21.00
1115 - 1273 33.00
1274 - 1432 47.00
1433 - 1591 63.00
1592 - 1750 82.00
1751 - 1909 103.00
1910 - 2069 126.00
2070 - 2228 152.00
2229 - 2387 180.00
2388 - 2546 210.00
2547 - 2705 242.00
2706 - 2864 277.00
2865 - 2944 299.00
Copayment A - Family Size 4
revised textMonthly Income revised amountsMonthly Copayment
$ 0 - 769 $ 2.00
770 - 961 3.00
962 - 1153 16.00
1154 - 1345 25.00
1346 - 1537 39.00
1538 - 1729 57.00
1730 - 1921 76.00
1922 - 2113 99.00
2114 - 2305 124.00
2306 - 2498 152.00
2499 - 2690 183.00
2691 - 2882 217.00
2883 - 3074 253.00
3075 - 3266 292.00
3267 - 3458 334.00
3459 - 3554 361.00
Copayment A - Family Size 5
revised textMonthly Income Monthly Copayment
$ 0 - 901 $ 2.00
902 - 1126 3.00
1127 - 1351 19.00
1352 - 1576 30.00
1577 - 1801 46.00
1802 - 2026 66.00
2027 - 2251 89.00
2252 - 2476 116.00
2477 - 2701 146.00
2702 - 2927 178.00
2928 - 3152 215.00
3153 - 3377 254.00
3378 - 3602 297.00
3603 - 3827 343.00
3828 - 4052 392.00
4053 - 4165 423.00
Copayment A - Family Size 6
revised textMonthly Income Monthly Copayment
$ 0 - 1033 $2.00
1034 - 1291 3.00
1292 - 1549 21.00
1550 - 1807 34.00
1808 - 2065 53.00
2066 - 2323 76.00
2324 - 2581 103.00
2582 - 2839 133.00
2840 - 3097 167.00
3098 - 3356 205.00
3357 - 3614 246.00
3615 - 3872 291.00
3873 - 4130 340.00
4131 - 4388 393.00
4389 - 4646 449.00
4647 - 4775 485.00
revised textCopayment A - Family Size 7
Monthly Income Monthly Copayment
$ 0 - 1165 $ 2.00
1166 - 1456 3.00
1457 - 1747 24.00
1748 - 2038 38.00
2039 - 2329 60.00
2330 - 2620 86.00
2621 - 2911 116.00
2912 - 3202 150.00
3203 - 3493 188.00
3494 - 3785 231.00
3786 - 4076 278.00
4077 - 4367 328.00
4368 - 4658 384.00
4659 - 4949 443.00
4950 - 5240 506.00
5241 - 5386 547.00
Copayment A - Family Size 8
revised textMonthly Income Monthly Copayment
$ 0 - 1297 $ 2.00
1298 - 1621 3.00
1622 - 1945 27.00
1946 - 2269 43.00
2270 - 2593 67.00
2594 - 2917 95.00
2918 - 3241 129.00
3242 - 3565 167.00
3566 - 3889 209.00
3890 - 4214 257.00
4215 - 4538 309.00
4539 - 4862 366.00
4863 - 5186 427.00
5187 - 5510 493.00
5511 - 5834 564.00
5835 - 5996 609.00
Copayment A - Family Size 9
revised textMonthly Income Monthly Copayment
$ 0 - 1429 $ 2.00
1430 - 1786 3.00
1787 - 2143 29.00
2144 - 2500 47.00
2501 - 2857 73.00
2858 - 3214 105.00
3215 - 3571 142.00
3572 - 3928 184.00
3929 - 4285 231.00
4286 - 4643 283.00
4644 - 5000  340.00
5001 - 5357 403.00
5358 - 5714 471.00
5715 - 6071 543.00
6072 - 6428 621.00
6429 - 6607 671.00
Copayment A - Family Size 10
revised textMonthly Income Monthly Copayment
$ 0 - 1561 $ 2.00
1562 - 1951 3.00
1952 - 2341 32.00
2342 - 2731 51.00
2732 - 3121 80.00
3122 - 3511 115.00
3512 - 3901 155.00
3902 - 4291 201.00
4292 - 4681 252.00
4682 - 5072 309.00
5073 - 5462 372.00
5463 - 5852 440.00
5853 - 6242 514.00
6243 - 6632 594.00
6633 - 7022 679.00
7023 - 7217 733.00