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 11.50
1,050 - 1,180 16.50
1,181 - 1,311 22.50
1,312 - 1,442 28.50
1,443 - 1,573 36.50
1,574 - 1,705 44.00
1,706 - 1,836 53.50
1,837 - 1,967 63.00
1,968 - 2,098 73.00
2,099 - 2,229 84.00
2,230 - 2,360 96.00
2,361 - 2,426 106.00
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 14.50
1321 - 1485 21.00
1486 - 1650 28.00
1651 - 1815 36.50
1816 - 1979 45.50
1980 - 2144 55.50
2145 - 2309 67.50
2310 - 2474 79.50
2475 - 2639 92.50
2640 - 2804 106.50
2805 - 2969 122.00
2970 - 3051 133.50

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 11.00
1393 - 1590 17.50
1591 - 1789 25.00
1790 - 1988 34.00
1989 - 2187 43.50
2188 - 2385 54.50
2386 - 2584 67.50
2585 - 2783 81.00
2784 - 2982 96.00
2983 - 3180 111.00
3181 - 3379 128.00
3380 - 3578 147.00
3579 - 3677 160.50
Copayment B - Family Size 5
Revised TextMonthly Income revised figuresMonthly Copayment
$ 0 - 931 $ 1.00
932 - 1163 1.50
1164 - 1396 8.00
1397 - 1629 13.50
1630 - 1861 21.00
1862 - 2094 29.00
2095 - 2326 40.00
2327 - 2559 51.50
2560 - 2791 64.50
2792 - 3024 79.00
3025 - 3257 95.00
3258 - 3489 111.50
3490 - 3722 130.50
3723 - 3954 151.00
3955 - 4187 172.00
4188 - 4303 188.00

Copayment B - Family Size 6

Revised TextMonthly Income revised figuresMonthly Copayment
$ 0 - 1066 $1.00
1067 - 1333  1.50
1334 - 1599 9.00
1600 - 1865 15.00
1866- 2132 24.00
2133 - 2398 34.00
2399 - 2665 45.50
2666 - 2931 58.50
2932 - 3197 73.50
3198 - 3464 90.50
3465 - 3730 108.50
3731 - 3997 127.50
3998 - 4263 149.50
4264 - 4530 172.50
4531 - 4796 196.50
4797 - 4929 216.00
Copayment B - Family Size 7
Revised TextMonthly Income revised figuresMonthly Copayment
$ 0 - 1,201 $ 1.00
1202 - 1502  1.50
1503 - 1802 10.50
1803 - 2102 17.00
2103 - 2402 26.50
2403 - 2703 38.50
2704 - 3003 51.50
3004 - 3303 66.50
3304 - 3603 83.50
3604 - 3904 101.50
3905-  4204 122.50
4205 - 4504 144.00
4505 - 4804 168.00
4805 - 5105 194.00
5106 - 5405 221.50
5406 - 5555 243.50
Copayment B - Family Size 8
Revised TextMonthly Income revised figuresMonthly Copayment
$ 0 - 1337 $ 1.00
1338 - 1671  1.50
1672 - 2005 11.50
2006 - 2339 19.50
2340 - 2673 29.50
2674 - 3007 42.00
3008 - 3341 57.00
3342 - 3675 73.50
3676 - 4009 92.50
4010- 4344 113.00
4345 - 4678 136.00
4679 - 5012 161.00
5013 - 5346 187.50
5347 - 5680 216.50
5681 - 6014 247.50
6015 - 6181 270.50
Copayment B - Family Size 9
Revised TextMonthly Income revised figuresMonthly Copayment
$ 0 - 1472 $ 1.00
1473 - 1840 1.50
1841 - 2208 12.50
2209 - 2576 21.50
2577 - 2944 32.50
2945 - 3312 46.50
3313 - 3680 63.00
3681 - 4048 81.50
4049 - 4415 101.50
4416 - 4783 125.00
4784 - 5151 150.00
5152 - 5519 177.00
5520 - 5887 207.00
5888 - 6255 237.50
6256 - 6623 272.00
6624 - 6807 298.00
Copayment B - Family Size 10
Revised TextMonthly Income revised figuresMonthly Copayment
$ 0 - 1607  $ 1.00
1608 - 2009 1.50
2010 - 2411 14.00
2412 - 2813 23.50
2814 - 3214 36.00
3215 - 3616 51.50
3617 - 4018 69.00
4019 - 4420 88.50
4421 - 4821 111.50
4822 - 5223 136.50
5224 - 5625 164.00
5626 - 6027 193.50
6028 - 6428 225.00
6429 - 6830 260.50
6831 - 7232 297.50
7233 - 7433 326.00