Effective 07/01/2019

Family Size 2 School-Age Co-payment

Monthly Income Monthly Co-Pay
$0-564 $1.00
565-705 1.50
706-846 5.50
847-987 9.00
988-1128 14.00
1129-1269 20.00
1270-1410 27.50
1411-1551 35.50
1552-1691 44.50
1692-1832 54.50
1833-1973 65.50
1974-2114 77.50
2115-2255 90.50
2256-2396 104.50
2397-2537 111.00
2538-2607 116.00
New Information2608-2678 119.00
2679-2819 123.50
2820-4307 123.50

Family Size 3 School-Age Co-Payment

Monthly Income Monthly Co-Pay
$0-711 $1.00
712-889 1.50
890-1067 7.00
1068-1245 11.50
1246-1422 18.00
1423-1600 25.50
1601-1778 34.50
1779-1956 44.50
1957-2133 56.00
2134-2311 68.50
2312-2489 82.50
2490-2667 97.50
2668-2844 114.00
2845-3022 132.00
3023-3200 140.00
3201-3289 146.00
New Information3290-3378 150.00
3379-3555 156.00
3556-5320 156.00

Family Size 4 School-Age Co-Payment

Monthly Income Monthly Co-Pay
$0-859 $1.00
860-1073 1.50
1074-1288 8.50
1289-1503 13.50
1504-1717 21.50
1718-1932 31.00
1933-2146 41.50
2147-2361 54.00
2362-2575 67.50
2576-2790 83.00
2791-3005 99.50
3006-3219 118.00
3220-3434 138.00
3435-3648 159.00
3649-3863 169.00
3864-3970 176.50
New Information3971-4078 181.00
4079-4292 188.50
4293-6333 188.50

Family Size 5 School-Age Co-Payment

Monthly Income Monthly Co-Pay
$0-1006 $1.00
1007-1258 1.50
1259-1509 10.00
1510-1760 16.00
1761-2012 25.00
2013-2263 36.00
2264-2515 48.50
2516-2766 63.00
2767-3017 79.00
3018-3269 97.00
3270-3520 117.00
3521-3772 138.50
3773-4023 161.50
4024-4275 186.50
4276-4526 198.00
4527-4652 206.50
New Information4653-4777 212.00
4778-5029 220.50
5030-7346 220.50

Family Size 6 School-Age Co-Payment

Monthly Income Monthly Co-Pay
$0-1153 $1.00
1154-1442 1.50
1443-1730 11.50
1731-2018 18.50
2019-2306 29.00
2307-2595 41.50
2596-2883 56.00
2884-3171 72.50
3172-3459 91.00
3460-3748 111.50
3749-4036 134.00
4037-4324 158.50
4325-4612 185.50
4613-4901 214.00
4902-5189 227.00
5190-5333 237.00
New Information5334-5477 243.50
5478-5765 253.00
5766-8359 253.00

Family Size 7 School-Age Co-Payment

Monthly Income Monthly Co-Pay
$0-1301 $1.00
1302-1626 1.50
1627-1951 13.00
1952-2276 21.00
2277-2601 32.50
2602-2926 46.50
2927-3251 63.00
3252-3576 81.50
3577-3901 102.50
3902-4227 125.50
4228-4552 151.00
4553-4877 179.00
4878-5202 209.00
5203-5527 241.50
5528-5852 256.00
5853-6015 267.00
New Information6016-6177 274.50
6178-6502 285.50
6503-8549 285.50

Family Size 8 School-Age Co-payment

Monthly Income Monthly Co-Pay
$0-1448 $1.00
1449-1810 1.50
1811-2172 14.50
2173-2534 23.00
2535-2896 36.50
2897-3258 52.00
3259-3620 70.00
3621-3982 91.00
3983-4343 114.00
4344-4705 140.00
4706-5067 168.50
5068-5429 199.00
5430-5791 232.50
5792-6153 268.50
6154-6515 285.00
6516-6696 297.50
New Information6697-6877 305.50
6878-7239 317.50
7240-8739 317.50

Family Size 9 School-Age Co-payment

Monthly Income Monthly Co-pay
$0-1595 $1.00
1596-1994 1.50
1995-2393 16.00
2394-2792 25.50
2793-3190 40.00
3191-3589 57.00
3590-3988 77.50
3989-4387 100.00
4388-4785 126.00
4786-5184 154.50
5185-5583 185.50
5584-5982 219.50
5983-6380 256.50
6381-6779 296.00
6780-7178 314.00
7179-7377 327.50
New Information7378-7577 336.50
7578-7975 350.00
7976-8929 350.00

Family Size 10 School-Age Co-Payment

Monthly Income Monthly Co-Pay
$0-1743 $1.00
1744-2178 1.50
2179-2614 17.50
2615-3050 28.00
3051-3485 43.50
3486-3921 62.50
3922-4356 84.50
4357-4792 109.50
4793-5227 137.50
5228-5663 168.50
5664-6099 202.50
6100-6534 240.00
6535-6970 280.00
6971-7405 323.50
7406-7841 343.00
7842-8059 358.00
New Information8060-8277 367.50
8278-8712 382.50
8713-9119 382.50