Copayment  B - Family Size 2

Revised TextMonthly Income Revised TextMonthly Copayment
$ 0 - 525 1.00
526 -   656 1.50
657 - 787 4.50
788 -  918 8.00
919 - 1,049 12.00
1,050 - 1,180 17.00
1,181 - 1,311 23.00
1,312 - 1,442 29.50
1,443 - 1,573 37.50
1,574 - 1,705 45.50
1,706 - 1,836 55.00
1,837 - 1,967 65.00
1,968 - 2,098 75.50
2,099 - 2,229 87.00
2,230 - 2,360 99.50
2,361 - 2,426 109.00
Copayment B - Family Size 3
Revised TextMonthly Income revised figuresMonthly Copayment
$ 0 - 660 $ 1.00
661 - 825 1.50
826 - 990  6.00
991 - 1155 10.00
1156 - 1320 15.00
1321 - 1485 21.50
1486 - 1650 29.00
1651 - 1815 37.50
1816 - 1979 47.00
1980 - 2144 57.50
2145 - 2309 69.50
2310 - 2474 82.00
2475 - 2639 95.50
2640 - 2804 110.00
2805 - 2969 126.00
2970 - 3051 137.50

Copayment B - Family Size 4

Revised TextMonthly Income revised figuresMonthly Copayment
$ 0 - 795 $ 1.00
796 - 994  1.50
995 - 1193  7.50
1194 - 1392 11.50
1393 - 1590 18.00
1591 - 1789 26.00
1790 - 1988 35.00
1989 - 2187 45.00
2188 - 2385 56.50
2386 - 2584 69.50
2585 - 2783 83.50
2784 - 2982 99.00
2983 - 3180 115.00
3181 - 3379 132.50
3380 - 3578 152.00
3579 - 3677 165.50
Copayment B - Family Size 5
Revised TextMonthly Income revised figuresMonthly Copayment
$ 0 - 931 $ 1.00
932 - 1163 1.50
1164 - 1396 8.50
1397 - 1629 14.00
1630 - 1861 21.50
1862 - 2094 30.00
2095 - 2326 41.00
2327 - 2559 53.00
2560 - 2791 66.50
2792 - 3024 81.50
3025 - 3257 98.00
3258 - 3489 115.50
3490 - 3722 135.00
3723 - 3954 156.00
3955 - 4187 178.00
4188 - 4303 194.00

Copayment B - Family Size 6

Revised TextMonthly Income revised figuresMonthly Copayment
$ 0 - 1066 $1.00
1067 - 1333  1.50
1334 - 1599 9.50
1600 - 1865 15.50
1866- 2132 24.50
2133 - 2398 35.00
2399 - 2665 47.00
2666 - 2931 60.50
2932 - 3197 76.00
3198 - 3464 93.50
3465 - 3730 112.00
3731 - 3997 132.00
3998 - 4263 154.50
4264 - 4530 178.50
4531 - 4796 203.50
4797 - 4929 222.50
Copayment B - Family Size 7
Revised TextMonthly Income revised figuresMonthly Copayment
$ 0 - 1,201 $ 1.00
1202 - 1502  1.50
1503 - 1802 11.00
1803 - 2102 17.50
2103 - 2402 27.50
2403 - 2703 39.50
2704 - 3003 53.00
3004 - 3303 68.50
3304 - 3603 86.00
3604 - 3904 105.00
3905-  4204 126.50
4205 - 4504 149.00
4505 - 4804 174.00
4805 - 5105 201.00
5106 - 5405 229.50
5406 - 5555 251.00
Copayment B - Family Size 8
Revised TextMonthly Income revised figuresMonthly Copayment
$ 0 - 1337 $ 1.00
1338 - 1671  1.50
1672 - 2005 12.00
2006 - 2339 20.00
2340 - 2673 30.50
2674 - 3007 43.50
3008 - 3341 59.00
3342 - 3675 76.00
3676 - 4009 95.50
4010- 4344 117.00
4345 - 4678 140.50
4679 - 5012 166.50
5013 - 5346 194.00
5347 - 5680 224.00
5681 - 6014 265.00
6015 - 6181 279.00
Copayment B - Family Size 9
Revised TextMonthly Income revised figuresMonthly Copayment
$ 0 - 1472 $ 1.00
1473 - 1840 1.50
1841 - 2208 13.00
2209 - 2576 22.00
2577 - 2944 33.50
2945 - 3312 48.00
3313 - 3680 65.00
3681 - 4048 84.00
4049 - 4415 105.00
4416 - 4783 129.00
4784 - 5151 155.00
5152 - 5519 183.00
5520 - 5887 214.00
5888 - 6255 246.00
6256 - 6623 281.50
6624 - 6807 307.50
Copayment B - Family Size 10
Revised TextMonthly Income revised figuresMonthly Copayment
$ 0 - 1607  $ 1.00
1608 - 2009 1.50
2010 - 2411 14.50
2412 - 2813 24.00
2814 - 3214 37.00
3215 - 3616 53.00
3617 - 4018 71.00
4019 - 4420 91.50
4421 - 4821 115.00
4822 - 5223 141.00
5224 - 5625 169.50
5626 - 6027 200.00
6028 - 6428 233.00
6429 - 6830 269.50
6831 - 7232 308.00
7233 - 7433 336.00