Family Size 2 School-Age Co-payment

Monthly Income Monthly Co-Pay
$0-542 $1.00
543-677 1.50
678-812 5.50
813-948 9.00
949-1083 14.00
1084-1218 20.00
1219-1354 27.00
1355-1489 35.00
1490-1624 44.00
1625-1760 53.50
1761-1895 64.50
1896-2030 76.50
2031-2166 89.00
Updated Co-pay Amount2167-2301 103.00
2302-2436 117.50
2437-2504 127.00

Family Size 3 School-Age Co-Payment

Monthly Income Monthly Co-Pay
$0-681 $1.00
682-851 1.50
852-1021 7.00
1022-1192 11.00
1193-1362 17.50
1363-1532 25.00
1533-1702 34.00
1703-1872 44.00
1873-2042 55.00
2043-2213 67.50
2214-2383 81.00
2384-2553 96.00
2554-2723 112.00
Updated Co-pay Amount2724-2893 129.50
2894-3063 148.00
3064-3149 160.00

Family Size 4 School-Age Co-Payment

Monthly Income Monthly Co-Pay
$0-820 $1.00
821-1025 1.50
1026-1230 8.50
1231-1435 13.50
1436-1640 21.00
1641-1845 30.00
1846-2050 40.50
2051-2265 52.50
2256-2460 66.50
2461-2665 81.00
2666-2870 97.50
2871-3075 115.50
3076-3280 135.00
Updated Co-pay Amount3281-3485 156.00
3486-3690 178.50
3691-3793 192.50

Family Size 5 School-Age Co-Payment

Monthly Income Monthly Co-Pay
$0-960 $1.00
961-1200 1.50
1201-1439 10.00
1440-1679 16.00
1680-1919 24.50
1920-2159 35.50
2160-2399 47.50
2400-2639 61.50
2640-2878 77.50
2879-3118 95.00
3119-3358 114.50
3359-3598 135.50
3599-3838 158.00
Updated Co-pay Amount3839-4078 182.50
4079-4317 208.50
4318-4437 225.50

Family Size 6 School-Age Co-Payment

Monthly Income Monthly Co-Pay
$0-1099 $1.00
1100-1374 1.50
1375-1648 11.50
1649-1923 18.00
1924-2198 28.00
2199-2472 40.50
2473-2747 54.50
2748-3022 70.50
3023-3296 89.00
3297-3571 109.00
3572-3846 131.00
3847-4120 155.00
4121-4395 181.0
Updated Co-pay Amount4396-4670 209.00
4671-4944 239.00
4945-5082 258.00

Family Size 7 School-Age Co-Payment

Monthly Income Monthly Co-Pay
$0-1238 $1.00
1239-1548 1.50
1549-1857 13.00
1858-2167 20.50
2168-2476 32.00
2477-2786 45.50
2787-3095 61.50
3096-3405 79.50
3406-3714 100.00
3715-4024 122.50
4025-4333 147.50
4334-4643 174.50
4644-4952 204.00
Updated Co-pay Amount4953-5262 235.50
5263-5571 269.00
5572-5726 291.00

Family Size 8 School-Age Co-payment

Monthly Income Monthly Co-Pay
$0-1378 $1.00
1379-1722 1.50
1723-2066 14.00
2067-2411 22.50
2412-2755 35.50
2756-3099 50.50
3100-3444 68.50
3445-3788 86.50
3789-4132 111.50
4133-4477 136.50
4478-4821 164.00
4822-5165 194.00
5166-5510 227.00
Updated Co-pay Amount5511-5854 262.00
5855-6198 299.50
6199-6371 323.50

Family Size 9 School-Age Co-payment

Monthly Income Monthly Co-pay
$0-1517 $1.00
1518-1896 1.50
1897-2275 15.50
2276-2655 25.00
2656-3034 39.00
3035-3413 56.00
3414-3792 75.50
3793-4171 97.50
4172-4550 122.50
4551-4930 150.50
4931-5309 180.50
5310-5688 214.00
5689-6067 250.00
Updated Co-pay Amount6068-6446 288.50
6447-6825 330.00
6826-7015 356.50

Family Size 10 School-Age Co-Payment

Monthly Income Monthly Co-Pay
$0-1656 $1.00
1657-2070 1.50
2071-2484 17.00
2485-2898 27.00
2899-3312 42.50
3313-3726 61.00
3727-4140 82.00
4141-4554 106.50
4555-4968 134.00
4969-5382 164.00
5383-5796 197.50
5797-6210 233.50
6211-6624 272.50
Updated Co-pay Amount6625-7038 315.00
7039-7452 360.00
7453-7659 389.00