Family Size 2

Monthly Income Monthly Co-Pay
$0 - $542 $2.00
543-677 3.00
678-812 11.00
813-948 18.00
949-1083 28.00
1084-1218 40.00
1219-1354 54.00
1355-1489 70.00
1490-1624 88.00
1625-1760 107.00
1761-1895 129.00
1896-2030 153.00
2031-2166 178.00
new co-pay amt2167-2301 206.00
2302-2436 235.00
2437-2504 254.00

Family Size 3

Monthly Income Monthly Co-Pay
$0-681 $2.00
682-851 3.00
852-1021 14.00
1022-1192 22.00
1193-1362 35.00
1363-1532 50.00
1533-1702 68.00
1703-1872 88.00
1873-2042 110.00
2043-2213 135.00
2214-2383 162.00
2384-2553 192.00
2554-2723 224.00
Updated Co-pay Amount2724-2893 259.00
2894-3063 296.00
3064-3149 320.00

Family Size 4

Monthly Income Monthly Co-Pay
$0-820 $2.00
821-1025 3.00
1026-1230 17.00
1231-1435 27.00
1436-1640 42.00
1641-1845 60.00
1846-2050 81.00
2051-2255 105.00
2256-2460 133.00
2461-2665 162.00
2666-2870 195.00
2871-3075 231.00
3076-3280 270.00
Updated Co-pay Amount3281-3485 312.00
3486-3690 357.00
3691-3793 385.00

Family Size 5

Monthly Income Monthly Co-Pay
$0-960 $2.00
961-1200 3.00
1201-1439 20.00
1440-1679 32.00
1680-1919 49.00
1920-2159 71.00
2160-2399 95.00
2400-2639 123.00
2640-2878 155.00
2879-3118 190.00
3119-3358 229.00
3359-3598 271.00
3599-3838 316.00
Updated Co-pay Amount3839-4078 365.00
4079-4317 417.00
4318-4437 451.00

Family Size 6

Monthly Income Monthly Co-Pay
$0-1099 $2.00
1100-1374 3.00
1375-1648 23.00
1649-1923 36.00
1924-2198 56.00
2199-2472 81.00
2473-2747 109.00
2748-3022 141.00
3023-3296 178.00
3297-3571 218.00
3572-3846 262.00
3847-4120 310.00
4121-4395 362.00
Updated Co-pay Amount4396-4670 418.00
4671-4944 478.00
4945-5082 516.00

Family Size 7

Monthly Income Monthly Co-Pay
$0-1238 $2.00
1239-1548 3.00
1549-1857 26.00
1858-2167 41.00
2168-2476 64.00
2477-2786 91.00
2787-3095 123.00
3096-3405 159.00
3406-3714 200.00
3715-4024 245.00
4025-4333 295.00
4334-4643 349.00
4644-4952 408.00
Updated Co-pay Amount4953-5262 471.00
5263-5571 538.00
5572-5726 582.00

Family Size 8

Monthly Income Monthly Co-Pay
$0-1378 $2.00
1379-1722 3.00
1723-2066 28.00
2067-2411 45.00
2412-2755 71.00
2756-3099 101.00
3100-3444 137.00
3445-3788 177.00
3789-4132 223.00
4133-4477 273.00
4478-4821 328.00
4822-5165 388.00
5166-5510 454.00
Updated Co-pay Amount5511-5854 524.00
5855-6198 599.00
6199-6371 647.00

Family Size 9

Monthly Income Monthly Co-Pay
$0-1517 $2.00
1518-1896 3.00
1897-2275 31.00
2276-2655 50.00
2656-3034 78.00
3035-3413 112.00
3414-3792 151.00
3793-4171 195.00
4172-4550 245.00
4551-4930 301.00
4931-5309 361.00
5310-5688 428.00
5689-6067 500.00
Updated Co-pay Amount6068-6446 577.00
6447-6825 660.00
6826-7015 713.00

Family Size 10

Monthly Income Monthly Co-Pay
$0-1656 $2.00
1657-2070 3.00
2071-2484 34.00
2485-2898 54.00
2899-3312 85.00
3313-3726 122.00
3727-4140 164.00
4141-4554 213.00
4555-4968 268.00
4969-5382 328.00
5383-5796 395.00
5797-6210 467.00
6211-6624 545.00
Updated Co-pay Amount6625-7038 630.00
7039-7452 720.00
7453-7659 778.00