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

New Manual MaterialCopayments Effective July 1, 2021

Family Size 2

Monthly Income Monthly Copayment
$ 0 - 1452 $ 1.00
1453 - 1597 15.00
1598 - 1742 33.00
1743 - 1887 54.00
1888 - 2032 78.00
2033 - 2178 105.00
2179 - 2323 135.00
2324 - 2468 168.00
2469 - 2613 178.00
2614 - 2758 188.00
2759 - 2903 198.00
2904 - 3049 208.00
3050 - 3194 219.00
3195 - 3266 226.00
3267 - 3629 241.00

Family Size 3

Monthly Income Monthly Copayment
$ 0 - 1830  $ 1.00
1831 - 2013 19.00
2014 - 2196 42.00
2197 - 2379 69.00
2380 - 2562 99.00
2563 - 2745 133.00
2746 - 2928 170.00
2929 - 3111 211.00
3112 - 3294 224.00
3295 - 3477 237.00
3478 - 3660 250.00
3661 - 3843 263.00
3844 - 4026 275.00
4027 - 4118 285.00
4119 - 4575 304.00

Family Size 4

Monthly Income Monthly Copayment
$ 0 - 2208  $ 1.00
2209 - 2429 23.00
2430 - 2650 51.00
2651 - 2871 83.00
2872 - 3092 119.00
3093 - 3313 160.00
3314 - 3533 205.00
3534 - 3754 255.00
3755 - 3975 271.00
3976 - 4196 286.00
4197 - 4417 301.00
4418 - 4638 317.00
4639 - 4858 332.00
4859 - 4969 344.00
4970 - 5521 367.00

Family Size 5

Monthly Income Monthly Copayment
$ 0 - 2587 $ 1.00
2588 - 2845 27.00
2846 - 3104 60.00
3105 - 3363 97.00
3364 - 3621 140.00
3622 - 3880 188.00
3881 - 4139 241.00
4140 - 4397 299.00
4398 - 4656 317.00
4657 - 4915 335.00
4916 - 5173 353.00
5174 - 5432 371.00
5433 - 5691 389.00
5692 - 5820 403.00
5821 - 6467 430.00

Family Size 6

Monthly Income Monthly Copayment
$ 0 - 2965 $ 1.00
2966 - 3262 31.00
3263 - 3558 68.00
3559 - 3855 111.00
3856 - 4151 160.00
4152 - 4448 215.00
4449 - 4744 276.00
4745 - 5041 343.00
5042 - 5337 363.00
5338 - 5634 384.00
5635 - 5930 405.00
5931 - 6227 426.00
6228 - 6523 446.00
6524 - 6671 462.00
6672 - 7413 493.00

Family Size 7

Monthly Income Monthly Copayment
$ 0 - 3343 $ 1.00
3344-3678 35.00
3679-4012 77.00
4013-4346 125.00
4347-4681 181.00
4682-5015 242.00
5016-5349 311.00
5350-5684 386.00
5685-6018 410.00
6019-6352 433.00
6353-6687 456.00
6688-7021 480.00
7022-7355 503.00
7356-7523 521.00
7524-8358 556.00

Family Size 8

Monthly Income Monthly Copayment
$ 0 - 3722 $ 1.00
3723 - 4094 39.00
4095 - 4466 86.00
4467 - 4838 140.00
4839 - 5210 201.00
5211 - 5583 270.00
5584 - 5955 346.00
5956 - 6327 430.00
6328 - 6699 456.00
6700 - 7071 482.00
7072 - 7443 508.00
7444 - 7816 534.00
7817 - 8188 560.00
8189 - 8374 580.00
8375 - 9304 619.00

Family Size 9

Monthly Income Monthly Copayment
$ 0 - 4100  $ 1.00
4101 - 4510 43.00
4511 - 4920 94.00
4921 - 5330 154.00
5331 - 5740 221.00
5741 - 6150 297.00
6151 - 6560 381.00
6561 - 6970 474.00
6971 - 7380 502.00
7381 - 7790 531.00
7791 - 8200 560.00
8201 - 8610 588.00
8611 - 9020 617.00
9021 - 9225 639.00
9226 - 10250 682.00

Family Size 10

Monthly Income Monthly Copayment
$ 0 - 4478 $ 1.00
4479 - 4926 47.00
4927 - 5374 103.00
5375 - 5822 168.00
5823 - 6270 242.00
6271 - 6718 325.00
6719 - 7165 417.00
7166 - 7613 517.00
7614 - 8061 549.00
8062 - 8509 580.00
8510 - 8957 611.00
8958 - 9405 643.00
9406 - 9852 674.00
9853 - 9958 698.00