Copayment  B - Family Size 2

Monthly Income revised figuresMonthly Copayment
$ 0 - 517 $ 1.00
518 - 647 1.50
648 - 776 4.50
777 - 905 8.00
906 - 1034 12.50
1035 - 1164 17.50
1165 - 1293 23.50
1294 - 1422 30.50
1423 - 1551 38.50
1552 - 1681 47.00
1682 - 1810 56.50
1811 - 1939 67.00
1940 - 2068 78.00
2069 - 2198 90.00
2199 - 2327 103.00
2328 - 2392 112.00

Copayment B - Family Size 3

Monthly Income revised figuresMonthly Copayment
$ 0 - 651 $ 1.00
652 - 814 1.50
815 - 977  6.00
978 - 1140 10.00
1141 - 1302 15.50
1303 - 1465 22.00
1466 - 1628 30.00
1629 - 1791 38.50
1792 - 1953 48.50
1954 - 2116 59.50
2117 - 2279 71.50
2280 - 2442 84.50
2443 - 2604 98.50
2605 - 2767 113.50
2768 - 2930 130.00
2931 - 3011 141.50

Copayment B - Family Size 4

Monthly Income revised figuresMonthly Copayment
$ 0 - 785 $ 1.00
786 - 982  1.50
983 - 1178  7.50
1179 - 1374 12.00
1375 - 1570 18.50
1571 - 1767 27.00
1768 - 1963 36.00
1964 - 2159 46.50
2160 - 2355 58.50
2356 - 2552 71.50
2553 - 2748 86.00
2749 - 2944 102.00
2945 - 3140 119.00
3141 - 3337 137.00
3338 - 3533 157.00
3534 - 3631 170.50
Copayment B - Family Size 5
Monthly Income revised figuresMonthly Copayment
$ 0 - 919 $ 1.00
920 - 1149 1.50
1150 - 1379 9.00
1380 - 1609 14.50
1610 - 1838 22.00
1839 - 2068 31.00
2069 - 2298 42.00
2299 - 2528 54.50
2529 - 2757 68.50
2758 - 2987 84.00
2988 - 3217 101.00
3218 - 3447 119.00
3448 - 3676 139.50
3677 - 3906 161.00
3907 - 4136 184.00
4137 - 4251 200.00

Copayment B - Family Size 6

Monthly Income revised figuresMonthly Copayment
$ 0 - 1053 $1.00
1054 - 1317  1.50
1318 - 1580 10.00
1581 - 1843 16.00
1844 - 2106 25.00
2107 - 2370 36.00
2371 - 2633 48.50
2634 - 2896 62.50
2897 - 3159 78.50
3160 - 3423 96.50
3424 - 3686 115.50
3687 - 3949 136.50
3950 - 4212 159.50
4213 - 4476 184.50
4477 - 4739 210.50
4740 - 4871 229.00
Copayment B - Family Size 7
Monthly Income revised figuresMonthly Copayment
$ 0 - 1,187 $ 1.00
1188 - 1484  1.50
1485 - 1781 11.50
1782 - 2078 18.00
2079 - 2374 28.50
2375 - 2671 40.50
2672 - 2968 54.50
2969 - 3265 70.50
3266 - 3561 88.50
3562 - 3858 108.50
3859- 4155 130.50
4156 - 4452 154.00
4453 - 4748 180.00
4749 - 5045 208.00
5046 - 5342 237.50
5343 - 5490 258.50
Copayment B - Family Size 8
Monthly Income revised figuresMonthly Copayment
$ 0 - 1321 $ 1.00
1322 - 1652  1.50
1653 - 1982 12.50
1983 - 2312 20.50
2313 - 2642 31.50
2643 - 2973 45.00
2974 - 3303 61.00
3304 - 3633 78.50
3634 - 3963 98.50
3964- 4294 121.00
4295 - 4624 145.00
4625 - 4954 172.00
4955 - 5284 200.50
5285 - 5615 231.50
5616 - 5945 264.50
5946 - 6110 287.50
Copayment B - Family Size 9
Monthly Income revised figuresMonthly Copayment
$ 0 - 1455 $ 1.00
1456 - 1819 1.50
1820 - 2183 13.50
2184 - 2547 22.50
2548 - 2910 34.50
2911 - 3274 49.50
3275 - 3638 67.00
3639 - 4002 86.50
4003 - 4365 108.50
4366 - 4729 133.00
4730 - 5093 160.00
5094 - 5457 189.00
5458 - 5820 221.00
5821 - 6184 254.50
6185 - 6548 291.00
6549 - 6730 317.00
Copayment B - Family Size 10
Monthly Income revised figuresMonthly Copayment
$ 0 - 1589  $ 1.00
1590 - 1987 1.50
1988 - 2384 15.00
2385 - 2781 24.50
2782 - 3178 38.00
3179 - 3576 54.50
3577 - 3973 73.00
3974 - 4370 94.50
4371 - 4767 118.50
4768 - 5165 145.50
5166 - 5562 175.00
5563 - 5959 206.50
5960 - 6356 241.00
6357 - 6754 278.50
6755 - 7151 318.50
7152 - 7350 346.00