WAG 25-03-14-b Table B Copayments

New Manual MaterialCopayments 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