New InformationCopayment Effective July 1, 2019

Family Size 2

Monthly Income Monthly Co-Pay
$0 - $564 $2.00
565-705 3.00
706-846 11.00
847-987 18.00
988-1128 28.00
1129-1269 40.00
1270-1410 55.00
1411-1551 71.00
1552-1691 89.00
1692-1832 109.00
1833-1973 131.00
1974-2114 155.00
2115-2255 181.00
2256-2396 209.00
2397-2537 222.00
2538-2607 232.00
New Information2608-2678 238.00
2679-2819 247.00
2820-4307 247.00

Family Size 3

Monthly Income Monthly Co-Pay
$0-711 $2.00
712-889 3.00
890-1067 14.00
1068-1245 23.00
1246-1422 36.00
1423-1600 51.00
1601-1778 69.00
1779-1956 89.00
1957-2133 112.00
2134-2311 137.00
2312-2489 165.00
2490-2667 195.00
2668-2844 228.00
2845-3022 264.00
3023-3200 280.00
3201-3289 292.00
New Information3290-3378 300.00
3379-3555 312.00
3556-5320 312.00

Family Size 4

Monthly Income Monthly Co-Pay
$0-859 $2.00
860-1073 3.00
1074-1288 17.00
1289-1503 27.00
1504-1717 43.00
1718-1932 62.00
1933-2146 83.00
2147-2361 108.00
2362-2575 135.00
2576-2790 166.00
2791-3005 199.00
3006-3219 236.00
3220-3434 276.00
3435-3648 318.00
3649-3863 338.00
3864-3970 353.00
New Information3971-4078 362.00
4079-4292 377.00
4293-6333 377.00

Family Size 5

Monthly Income Monthly Co-Pay
$0-1006 $2.00
1007-1258 3.00
1259-1509 20.00
1510-1760 32.00
1761-2012 50.00
2013-2263 72.00
2264-2515 97.00
2516-2766 126.00
2767-3017 158.00
3018-3269 194.00
3270-3520 234.00
3521-3772 277.00
3773-4023 323.00
4024-4275 373.00
4276-4526 396.00
4527-4652 413.00
New Information4653-4777 424.00
4778-5029 441.00
5030-7346 441.00

Family Size 6

Monthly Income Monthly Co-Pay
$0-1153 $2.00
1154-1442 3.00
1443-1730 23.00
1731-2018 37.00
2019-2306 58.00
2307-2595 83.00
2596-2883 112.00
2884-3171 145.00
3172-3459 182.00
3460-3748 223.00
3749-4036 268.00
4037-4324 317.00
4325-4612 371.00
4613-4901 428.00
4902-5189 454.00
5190-5333 474.00
New Information5334-5477 487.00
5478-5765 506.00
5766-8359 506.00

Family Size 7

Monthly Income Monthly Co-Pay
$0-1301 $2.00
1302-1626 3.00
1627-1951 26.00
1952-2276 42.00
2277-2601 65.00
2602-2926 93.00
2927-3251 126.00
3252-3576 163.00
3577-3901 205.00
3902-4227 251.00
4228-4552 302.00
4553-4877 358.00
4878-5202 418.00
5203-5527 483.00
5528-5852 512.00
5853-6015 534.00
New Information6016-6177 549.00
6178-6502 571.00
6503-8549 571.00

Family Size 8

Monthly Income Monthly Co-Pay
$0-1448 $2.00
1449-1810 3.00
1811-2172 29.00
2173-2534 46.00
2535-2896 73.00
2897-3258 104.00
3259-3620 140.00
3621-3982 182.00
3983-4343 228.00
4344-4705 280.00
4706-5067 337.00
5068-5429 398.00
5430-5791 465.00
5792-6153 537.00
6154-6515 570.00
6516-6696 595.00
New Information6697-6877 611.00
6878-7239 635.00
7240-8739 635.00

Family Size 9

Monthly Income Monthly Co-Pay
$0-1595 $2.00
1596-1994 3.00
1995-2393 32.00
2394-2792 51.00
2793-3190 80.00
3191-3589 114.00
3590-3988 155.00
3989-4387 200.00
4388-4785 252.00
4786-5184 308.00
5185-5583 371.00
5584-5982 439.00
5983-6380 513.00
6381-6779 592.00
6780-7178 628.00
7197-7377 655.00
New Information7378-7577 673.00
7578-7975 700.00
7976-8929 700.00

Family Size 10

Monthly Income Monthly Co-Pay
$0-1743 $2.00
1744-2178 3.00
2179-2614 35.00
2615-3050 56.00
3051-3485 87.00
3486-3921 125.00
3922-4356 169.00
4357-4792 219.00
4793-5227 275.00
5228-5663 337.00
5664-6099 405.00
6100-6534 480.00
6535-6970 560.00
6971-7405 647.00
7406-7841 686.00
7842-8059 716.00
New Information8060-8277 735.00
8278-8712 765.00
8713-9119 765.00