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 24.00
1050 - 1180 34.00
1181 - 1311 46.00
1312 - 1442 59.00
1443 - 1573 75.00
1574 - 1705 91.00
1706 - 1836 110.00
1837 - 1967 130.00
1968 - 2098 151.00
2099 - 2229 174.00
2230 - 2360 199.00
2361 - 2426 218.00
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 30.00
1321 - 1485 43.00
1486 - 1650 58.00
1651 - 1815 75.00
1816 - 1979 94.00
1980 - 2144 115.00
2145 - 2309 139.00
2310 - 2474 164.00
2475 - 2639 191.00
2640 - 2804 220.00
2805 - 2969 252.00
2970 - 3051 275.00
Copayment A - Family Size 4
Monthly Income revised amountsMonthly Copayment
$ 0 - 795 $ 2.00
796 - 994 3.00
995 - 1193 15.00
1194 - 1392 23.00
1393 - 1590 36.00
1591 - 1789 52.00
1790 - 1988 70.00
1989 - 2187 90.00
2188 - 2385 113.00
2386 - 2584 139.00
2585 - 2783 167.00
2784 - 2982 198.00
2983 - 3180 230.00
3181 - 3379 265.00
3380 - 3578 304.00
3579 - 3677 331.00
Copayment A - Family Size 5
revised textMonthly Income Revised TextMonthly Copayment
$ 0 - 931 $ 2.00
932 - 1163 3.00
1164 - 1396 17.00
1397- 1629 28.00
1630 - 1861 43.00
1862 - 2094 60.00
2095 - 2326 82.00
2327 - 2559 106.00
2560 - 2791 133.00
2792 - 3024 163.00
3025 - 3257 196.00
3258 - 3489 231.00
3490 - 3722 270.00
3723- 3954 312.00
3955 - 4187 356.00
4188 - 4303 388.00
Copayment A - Family Size 6
Revised TextMonthly Income revised textMonthly Copayment
$ 0 - 1066 $2.00
1067 - 1333 3.00
1334 - 1599 19.00
1600 - 1865 31.00
1866 - 2132 49.00
2133 - 2398 70.00
2399 - 2665 94.00
2666 - 2931 121.00
2932 - 3197 152.00
3198 - 3464 187.00
3465 - 3730 224.00
3731 - 3997 264.00
3998 - 4263 309.00
4264 - 4530 357.00
4531 - 4796 407.00
4797 - 4929 445.00
Copayment A - Family Size 7
Revised TextMonthly Income revised textMonthly Copayment
$ 0 - 1201 $ 2.00
1202 - 1502 3.00
1503 - 1802 22.00
1803 - 2102 35.00
2103 - 2402 55.00
2403 - 2703 79.00
2704 - 3003 106.00
3004 - 3303 137.00
3304 - 3603 172.00
3604 - 3904 210.00
3905 - 4204 253.00
4205 - 4504 298.00
4505 - 4804 348.00
4805 - 5105 402.00
5106 - 5405 459.00
5406 - 5555 502.00
Copayment A - Family Size 8
Revised TextMonthly Income revised textMonthly Copayment
$ 0 - 1337 $ 2.00
1338 - 1671 3.00
1672 - 2005 24.00
2006 - 2339 40.00
2340 - 2673 61.00
2674 - 3007 87.00
3008 - 3341 118.00
3342 - 3675 152.00
3676 - 4009 191.00
4010 - 4344 234.00
4345 - 4678 281.00
4679 - 5012 333.00
5013 - 5346 388.00
5347 - 5680 448.00
5681 - 6014 512.00
6015 - 6181 558.00
Copayment A - Family Size 9
Revised TextMonthly Income revised textMonthly Copayment
$ 0 - 1472 $ 2.00
1473 - 1840 3.00
1841 - 2208 26.00
2209 - 2576 44.00
2577 - 2944 67.00
2945 - 3312 96.00
3313 - 3680 130.00
3681 - 4048 168.00
4049 - 4415 210.00
4416 - 4783 258.00
4784 - 5151  310.00
5152 - 5519 366.00
5520 - 5887 428.00
5888 - 6255 492.00
6256 - 6623 563.00
6624 - 6807 615.00
Copayment A - Family Size 10
Revised TextMonthly Income revised textMonthly Copayment
$ 0 - 1607 $ 2.00
1608 - 2009 3.00
2010 - 2411 29.00
2412 - 2813 48.00
2814 - 3214 74.00
3215 - 3616 106.00
3617 - 4018 142.00
4019 - 4420 183.00
4421 - 4821 230.00
4822 - 5223 282.00
5224 - 5625 339.00
5626 - 6027 400.00
6028 - 6428 466.00
6429 - 6830 539.00
6831 - 7232 616.00
7233 - 7433 672.00