Copayments Effective July 1, 2021
Family Size 2 School Age Copayments
| Monthly Income |
Monthly Copayment |
| $ 0-1452 |
$ .50 |
| 1453-1597 |
7.50 |
| 1598-1742 |
16.50 |
| 1743-1887 |
27.00 |
| 1888-2032 |
39.00 |
| 2033-2178 |
52.50 |
| 2179-2323 |
67.50 |
| 2324-2468 |
84.00 |
| 2469-2613 |
89.00 |
| 2614-2758 |
94.00 |
| 2759-2903 |
99.00 |
| 2904-3049 |
104.00 |
| 3050-3194 |
109.50 |
| 3195-3266 |
113.00 |
| 3267-3629 |
120.50 |
Family Size 3 School Age Copayments
| Monthly Income |
Monthly Copayment |
| $ 0-1830 |
$ .50 |
| 1831-2013 |
9.50 |
| 2014-2196 |
21.00 |
| 2197-2379 |
34.50 |
| 2380-2562 |
49.50 |
| 2563-2745 |
66.50 |
| 2746-2928 |
85.00 |
| 2929-3111 |
105.50 |
| 3112-3294 |
112.00 |
| 3295-3477 |
118.50 |
| 3478-3660 |
125.00 |
| 3661-3843 |
131.50 |
| 3844-4026 |
137.50 |
| 4027-4118 |
142.50 |
| 4119-4575 |
152.00 |
Family Size 4 School Age Copayments
| Monthly Income |
Monthly Copayment |
| $ 0-2208 |
$.50 |
| 2209-2429 |
11.50 |
| 2430-2650 |
25.50 |
| 2651-2871 |
41.50 |
| 2872-3092 |
59.50 |
| 3093-3313 |
80.00 |
| 3314-3533 |
102.50 |
| 3534-3754 |
127.50 |
| 3755-3975 |
135.50 |
| 3976-4196 |
143.00 |
| 4197-4417 |
150.50 |
| 4418-4638 |
158.50 |
| 4639-4858 |
166.00 |
| 4859-4969 |
172.00 |
| 4970-5521 |
183.50 |
Family Size 5 School Age Copayments
| Monthly Income |
Monthly Copayment |
| $ 0-2587 |
$.50 |
| 2588-2845 |
13.50 |
| 2846-3104 |
30.00 |
| 3105-3363 |
48.50 |
| 3364-3621 |
70.00 |
| 3622-3880 |
94.00 |
| 3881-4139 |
120.50 |
| 4140-4397 |
149.50 |
| 4398-4656 |
158.50 |
| 4657-4915 |
167.50 |
| 4916-5173 |
176.50 |
| 5174-5432 |
185.50 |
| 5433-5691 |
194.50 |
| 5692-5820 |
201.50 |
| 5821-6467 |
215.00 |
Family Size 6 School Age Copayments
| Monthly Income |
Monthly Copayment |
| $ 0-2965 |
$ 0.50 |
| 2966-3262 |
15.50 |
| 3263-3558 |
34.00 |
| 3559-3855 |
55.50 |
| 3856-4151 |
80.00 |
| 4152-4448 |
107.50 |
| 4449-4744 |
138.00 |
| 4745-5041 |
171.50 |
| 5042-5337 |
181.50 |
| 5338-5634 |
192.00 |
| 5365-5930 |
202.50 |
| 5931-6227 |
213.00 |
| 6228-6523 |
223.00 |
| 6524-6671 |
231.00 |
| 6672-7413 |
246.50 |
Family Size 7 School Age Copayments
| Monthly Income |
Monthly Copayment |
| $ 0-3343 |
$.50 |
| 3344-3678 |
17.50 |
| 3679-4012 |
38.50 |
| 4013-4346 |
62.50 |
| 4347-4681 |
90.50 |
| 4681-5015 |
121.00 |
| 5016-5349 |
155.50 |
| 5350-5684 |
193.00 |
| 5685-6018 |
205.00 |
| 6019-6352 |
216.50 |
| 6353-6687 |
228.00 |
| 6688-7021 |
240.00 |
| 7022-7355 |
251.50 |
| 7356-7523 |
260.50 |
| 7524-8358 |
278.00 |
Family Size 8 School Age Copayments
| Monthly Income |
Monthly Copayment |
| $ 0-3722 |
$ .50 |
| 3723-4094 |
19.50 |
| 4095-4466 |
43.00 |
| 4467-4838 |
70.00 |
| 4839-5210 |
100.50 |
| 5211-5583 |
135.00 |
| 5584-5955 |
173.00 |
| 5956-6327 |
215.00 |
| 6328-6699 |
228.00 |
| 6700-7071 |
241.00 |
| 7072-7443 |
254.00 |
| 7444-7816 |
267.00 |
| 7817-8188 |
280.00 |
| 8189-8374 |
290.00 |
| 8375-9304 |
309.50 |
Family Size 9 School Age Copayments
| Monthly Income |
Monthly Copayment |
| $ 0-4100 |
$ .50 |
| 4101-4510 |
21.50 |
| 4511-4920 |
47.00 |
| 4921-5330 |
77.00 |
| 5331-5740 |
110.50 |
| 5741-6150 |
148.50 |
| 6151-6560 |
190.50 |
| 6561-6970 |
237.00 |
| 6971-7380 |
251.00 |
| 7381-7790 |
265.50 |
| 7791-8200 |
280.00 |
| 8201-8610 |
294.00 |
| 8611-9020 |
308.50 |
| 9021-9225 |
319.50 |
| 9226-9751 |
341.00 |
Family Size 10 School Age Copayments
| Monthly Income |
Monthly Copayment |
| $ 0-4478 |
$ .50 |
| 4479-4926 |
23.50 |
| 4927-5374 |
51.50 |
| 5375-5822 |
84.00 |
| 5823-6270 |
121.00 |
| 6271-6718 |
162.50 |
| 6719-7165 |
208.50 |
| 7166-7613 |
258.50 |
| 7614-8061 |
274.50 |
| 8062-8509 |
290.00 |
| 8510-8957 |
305.50 |
| 8958-9405 |
321.50 |
| 9406-9852 |
337.50 |
| 9853-9958 |
349.00 |
