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

New Manual MaterialCopayments Effective July 1, 2020

Family Size 2

Monthly Income Monthly Copayment
$ 0 - 575 $ 2.00
576-719 3.00
720-862 12.00
863-1006 18.00
1007-1150 29.00
1151-1293 41.00
1294-1437 55.00
1438-1581 72.00
1582-1724 90.00
1725-1868 111.00
1869-2012 133.00
2013-2155 146.00
2156-2299 156.00
2300-2443 166.00
2444-2586 176.00
2587-2730 186.00
2731-2874 196.00
2875-3017 206.00
3018-3161 216.00
3162-3233 224.00

Family Size 3

Monthly Income Monthly Copayment
$ 0-724 $ 2.00
725-905 3.00
906-1086 15.00
1087-1267 23.00
1268-1448 36.00
1449-1629 52.00
1630-1810 70.00
1811-1991 90.00
1992-2172 114.00
2173-2353 139.00
2354-2534 168.00
2535-2715 184.00
2716-2896 196.00
2897-3077 209.00
3078-3258 222.00
3259-3439 234.00
3440-3620 247.00
3621-3801 328.00
3802-3982 344.00
3983-4073 356.00

Family Size 4

Monthly Income Monthly Copayment
$ 0-874 $ 2.00
875-1092 3.00
1093-1310 18.00
1311-1529 28.00
1530-1747 44.00
1748-1965 62.00
1966-2184 84.00
2185-2402 109.00
2403-2620 137.00
2621-2839 168.00
2840-3057 202.00
3058-3275 222.00
3276-3494 237.00
3495-3712 252.00
3713-3930 268.00
3931-4149 283.00
4150-4367 298.00
4368-4585 313.00
4586-4804 329.00
4805-4913 340.00

Family Size 5

Monthly Income Monthly Copayment
$ 0-1023 $ 2.00
1024-1279 3.00
1280-1534 21.00
1535-1790 33.00
1791-2046 51.00
2047-2301 73.00
2302-2557 99.00
2558-2813 128.00
2814-3068 161.00
3069-3324 197.00
3325-3580 237.00
3581-3835 260.00
3836-4091 277.00
4092-4347 295.00
4348-4602 313.00
4603-4858 331.00
4859-5114 349.00
5115-5369 367.00
5370-5625 385.00
5626-5753 398.00

Family Size 6

Monthly Income Monthly Copayment
$ 0-1172 $ 2.00
1173-1465 3.00
1466-1758 24.00
1759-2051 37.00
2052-2344 58.00
2345-2637 84.00
2638-2930 113.00
2931-3223 146.00
3224-3516 184.00
3517-3809 226.00
3810-4102 271.00
4103-4395 297.00
4396-4688 318.00
4689-4981 338.00
4982-5274 359.00
5275-5567 379.00
5568-5860 400.00
5861-6153 420.00
6154-6446 441.00
6447-6593 456.00

Family Size 7

Monthly Income Monthly Copayment
$ 0-1322 $ 2.00
1323-1652 3.00
1653-1982 27.00
1983-2313 42.00
2314-2643 66.00
2644-2973 94.00
2974-3304 127.00
3305-3634 165.00
3635-3964 207.00
3965-4295 254.00
4296-4625 306.00
4626-4955 335.00
4956-5286 358.00
5287-5616 382.00
5617-5946 405.00
5947-6277 428.00
6278-6607 451.00
6608-6937 474.00
6938-7268 497.00
7269-7433 515.00

Family Size 8

Monthly Income Monthly Copayment
$ 0-1471 $ 2.00
1472-1839 3.00
1840-2206 30.00
2207-2574 47.00
2575-2942 73.00
2943-3309 105.00
3310-3677 142.00
3678-4045 184.00
4046-4412 231.00
4413-4780 283.00
4781-5148 341.00
5149-5515 373.00
5516-5883 399.00
5884-6251 425.00
6252-6618 450.00
6619-6986 476.00
6987-7354 502.00
7355-7721 528.00
7722-8089 553.00
8090-8273 573.00

Family Size 9

Monthly Income Monthly Copayment
$ 0-1620 $ 2.00
1621-2025 3.00
2026-2430 33.00
2431-2835 52.00
2836-3240 81.00
3241-3645 116.00
3646-4050 156.00
4051-4455 202.00
4456-4860 254.00
4861-5265 312.00
5266-5670 375.00
5671-6075 411.00
6076-6480 439.00
6481-6885 468.00
6886-7290 496.00
7291-7695 525.00
7696-8100 553.00
8101-8505 581.00
8506-8910 610.00
8911-9113 631.00

Family Size 10

Monthly Income Monthly Copayment
$ 0-1770 $ 2.00
1771-2212 3.00
2213-2654 36.00
2655-3097 56.00
3098-3539 88.00
3540-3981 126.00
3982-4424 171.00
4425-4866 221.00
4867-5308 278.00
5309-5751 341.00
5752-6193 410.00
6194-6635 449.00
6636-7078 480.00
7079-7520 511.00
7521-7962 542.00
7963-8405 573.00
8406-8847 604.00
8848-9289 635.00
9290-9732 666.00
9733-9953 689.00