WAG 25-03-14-a: Table A Copayments

New Manual MaterialCopayments Effective July 1, 2022

Family Size 2

Monthly Income Monthly Copayment
$ 0 - 1526 $ 1.00
1527 - 1678 16.00
1679 - 1831 35.00
1832 - 1984 57.00
1985 - 2136 82.00
2137 - 2289 111.00
2290 - 2441 142.00
2442 - 2594 176.00
2595 - 2747 187.00
2748 - 2899 198.00
2900 - 3052 208.00
3053 - 3204 219.00
3205 - 3357 230.00
3358 - 3433 238.00

Family Size 3

Monthly Income Monthly Copayment
$0 - 1919 $1.00
1920 - 2111 20.00
2112 - 2303 44.00
2304 - 2495 72.00
2496 - 2687 104.00
2688 - 2879 139.00
2880 - 3071 179.00
3072 - 3263 222.00
3264 - 3455 235.00
3456 - 3646 249.00
3647 - 3838 262.00
3839 - 4030 275.00
4031 - 4222 289.00
4223 - 4318 299.00

Family Size 4

Monthly Income Monthly Copayment
 $0 - 2313 $1.00
2314 - 2544 24.00
2545 - 2775 53.00
2776 - 3006 87.00
3007 - 3238 125.00
3239 - 3469 168.00
3470 - 3700 215.00
3701 - 3931 267.00
3932 - 4163 283.00
4164 - 4394 300.00
4395 - 4625 316.00
4626 - 4856 332.00
4857 - 5088 348.00
5089 - 5203 360.00

Family Size 5

Monthly Income Monthly Copayment
$0 - 2706  1.00
2707 - 2976  28.00
2977 - 3247 62.00
3248 - 3518 101.00
3519 - 3788  146.00
3789 - 4059  196.00
4060 - 4329  252.00
4330 - 4600  313.00
4601 - 4871  332.00
4872 - 5141  350.00
5142 - 5412  369.00
5413 - 5682  388.00
5683 - 5953  407.00
5954 - 6088  421.00

Family Size 6

Monthly Income Monthly Copayment
$0 - 3099  1.00
3100 - 3409  33.00
3410 - 3719  71.00
3720 - 4029 116.00
4030 - 4339  167.00
4340 - 4649  225.00
4650 - 4959  288.00
4960 - 5269  358.00
5270 - 5579  380.00
5580 - 5888  401.00
5889 - 6198  423.00
6199 - 6508  445.00
6509 - 6618  466.00
6819 - 6973  483.00

Family Size 7

Monthly Income Monthly Copayment
$0 - 3493  1.00
3494 - 3842  37.00
3843 - 4191  80.00
4192 - 4540  131.00
4541 - 4890  189.00
4891 - 5239  253.00
5240 - 5588  325.00
5589 - 5937  403.00
5938 - 6287  428.00
6288 - 6636  452.00
6637 - 6985 477.00
6986 - 7334  501.00
7335 - 7684 526.00
7685 - 7858  544.00

Family Size 8

Monthly Income Monthly Copayment
$0 - 3886  1.00
3887 - 4274  41.00
4275 - 4663  89.00
4664 - 5052  146.00
5053 - 5440  210.00
5441 - 5829  282.00
5830 - 6217  361.00
6218 - 6606  449.00
6607 - 6995  476.00
6996 - 7383  503.00
7384 - 7772  530.00
7773 - 8160  558.00
8161 - 8549  585.00
8550 - 8743  605.00

Family Size 9

Monthly Income Monthly Copayment
$0 - 4279  1.00
4280 - 4707  45.00
4708 - 5135  98.00
 5136 - 5563 161.00
5564 - 5991  231.00
5992 - 6419  310.00
6420 - 6847  398.00
6848 - 7275  494.00
7276 - 7703 524.00
7704 - 8130  554.00
8131 - 8558 584.00
8559 - 8986 614.00
8987 - 9414  644.00
9415 - 9628  667.00

Family Size 10

Monthly Income Monthly Copayment
$0 - 4673  1.00
4674 - 5140  49.00
5141 - 5607  107.00
5608 - 6074  175.00
6075 - 6542  252.00
6543 - 7009  339.00
7010 - 7476  435.00
7477 - 7943  540.00
7944 - 8411  572.00
8412 - 8878  605.00
8879 - 9345  638.00
9346 - 9812  671.00
9813 - 10280  703.00
10281 - 10421  728.00