Copayments Effective July 1, 2022
Family Size 2 School Age Copayments
| Monthly Income |
Monthly Copayment |
| $ 0-1526 |
$ 0.50 |
| 1527-1678 |
8.00 |
| 1679-1831 |
17.50 |
| 1832-1984 |
28.50 |
| 1985-2136 |
41.00 |
| 2137-2289 |
55.50 |
| 2290-2441 |
71.00 |
| 2442-2594 |
88.00 |
| 2595-2747 |
93.50 |
| 2748-2899 |
99.00 |
| 2900-3052 |
104.00 |
| 3053-3204 |
109.50 |
| 3205-3357 |
115.00 |
| 3358-3433 |
119.00 |
Family Size 3 School Age Copayments
| Monthly Income |
Monthly Copayment |
| $ 0-1919 |
$ 0.50 |
| 1920-2111 |
10.00 |
| 2112-2303 |
22.00 |
| 2304-2495 |
36.00 |
| 2496-2687 |
52.00 |
| 2688-2879 |
69.50 |
| 2880-3071 |
89.50 |
| 3072-3263 |
111.00 |
| 3264-3455 |
117.50 |
| 3456-3646 |
124.50 |
| 3647-3838 |
131.00 |
| 3839-4030 |
137.50 |
| 4031-4222 |
144.50 |
| 4223-4318 |
149.50 |
Family Size 4 School Age Copayments
| Monthly Income |
Monthly Copayment |
| $ 0-2313 |
$ 0.50 |
| 2314-2544 |
12.00 |
| 2545-2775 |
26.50 |
| 2776-3006 |
43.50 |
| 3007-3238 |
62.50 |
| 3239-3469 |
84.00 |
| 3470-3700 |
107.50 |
| 3701-3931 |
133.50 |
| 3932-4163 |
141.50 |
| 4164-4394 |
150.00 |
| 4395-4625 |
158.00 |
| 4626-4856 |
166.00 |
| 4857-5088 |
174.00 |
| 5089 - 5203 |
180.00 |
Family Size 5 School Age Copayments
| Monthly Income |
Monthly Copayment |
| $ 0-2706 |
$ 0.50 |
| 2707-2976 |
14.00 |
| 2977-3247 |
31.00 |
| 3248-3518 |
50.50 |
| 3519-3788 |
73.00 |
| 3789-4059 |
98.00 |
| 4060-4329 |
126.00 |
| 4330-4600 |
156.50 |
| 4601-4871 |
166.00 |
| 4872-5141 |
175.00 |
| 5142-5412 |
184.50 |
| 5413-5682 |
194.00 |
| 5683-5953 |
203.50 |
| 5954-6088 |
210.50 |
Family Size 6 School Age Copayments
| Monthly Income |
Monthly Copayment |
| $0 - 3099 |
$ 0.50 |
| 3100-3409 |
16.50 |
| 3410-3719 |
35.50 |
| 3720-4029 |
58.00 |
| 4030-4339 |
83.50 |
| 4340-4649 |
112.50 |
| 4650-4959 |
144.00 |
| 4960-5269 |
179.00 |
| 5270-5579 |
190.00 |
| 5580-5888 |
200.50 |
| 5889-6198 |
211.50 |
| 6199-6508 |
222.50 |
| 6509-6818 |
233.00 |
| 6819-6973 |
241.50 |
Family Size 7 School Age Copayments
| Monthly Income |
Monthly Copayment |
| $ 0-3493 |
$ 0.50 |
| 3494-3842 |
18.50 |
| 3843-4191 |
40.00 |
| 4192-4540 |
65.50 |
| 4541-4890 |
94.50 |
| 4891-5239 |
126.50 |
| 5240-5588 |
162.50 |
| 5589-5937 |
201.50 |
| 5938-6287 |
214.00 |
| 6288-6636 |
226.00 |
| 6637-6985 |
238.50 |
| 6986-7334 |
250.50 |
| 7335-7684 |
263.00 |
| 7685-7858 |
272.00 |
Family Size 8 School Age Copayments
| Monthly Income |
Monthly Copayment |
| $ 0 - 3866 |
$ 0.50 |
| 3887-4274 |
20.50 |
| 4275-4663 |
44.50 |
| 4664-5052 |
73.00 |
| 5053-5440 |
105.00 |
| 5441-5829 |
141.00 |
| 5830-6217 |
180.50 |
| 6218-6606 |
224.50 |
| 6607-6995 |
238.00 |
| 6996-7383 |
251.50 |
| 7384-7772 |
265.00 |
| 7773-8160 |
279.00 |
| 8161-8549 |
292.50 |
| 8550-8743 |
302.50 |
Family Size 9 School Age Copayments
| Monthly Income |
Monthly Copayment |
| $ 0-4279 |
$ 0.50 |
| 4280-4707 |
22.50 |
| 4708-5135 |
49.00 |
| 5136-5563 |
80.50 |
| 5564-5991 |
115.50 |
| 5992-6419 |
155.00 |
| 6420-6847 |
199.00 |
| 6848-7275 |
247.00 |
| 7276-7703 |
262.00 |
| 7704-8130 |
277.00 |
| 8131-8558 |
292.00 |
| 8559-8986 |
307.00 |
| 8987-9414 |
322.00 |
| 9415-9628 |
333.50 |
Family Size 10 School Age Copayments
| Monthly Income |
Monthly Copayment |
| $ 0-4673 |
$ 0.50 |
| 4674-5140 |
24.50 |
| 5141-5607 |
53.50 |
| 5608-6074 |
87.50 |
| 6075-6542 |
126.00 |
| 6543-7009 |
169.50 |
| 7010-7476 |
217.50 |
| 7477-7943 |
270.00 |
| 7944-8411 |
286.00 |
| 8412-8878 |
302.50 |
| 8879-9345 |
319.00 |
| 9346-9812 |
335.50 |
| 9813-10280 |
351.50 |
| 10281-10421 |
364.00 |
