Pennsylvania Bulletin

PA Bulletin, Doc. No. 20-1570c

[50 Pa.B. 6361]
[Saturday, November 14, 2020]

[Continued from previous Web Page]

APPENDIX B

Co-Payment Chart

Family Co-Payment Scale Effective May 4, 2020

(Based on the 2020 Federal Poverty Income Guidelines)

Weekly
Co-pay Family Size: 1
Annual Income Weekly
Co-pay Family Size: 2
Annual Income Weekly
Co-pay Family Size: 3
Annual Income

$5 Less than: $5,997 $5 Less than: $7,090 $5 Less than: $7,656

$6 $5,997.01 $6,747 $7 $7,090.01 $8,103 $7 $7,656.01 $8,932

$7 $6,747.01 $7,497 $8 $8,103.01 $9,116 $8 $8,932.01 $10,208

$8 $7,497.01 $8,246 $10 $9,116.01 $10,129 $10 $10,208.01 $11,484

$10 $8,246.01 $8,996 $11 $10,129.01 $11,141 $12 $11,484.01 $12,761

$11 $8,996.01 $9,745 $13 $11,141.01 $12,154 $14 $12,761.01 $14,037

$12 $9,745.01 $10,495 $15 $12,154.01 $13,167 $16 $14,037.01 $15,313

$14 $10,495.01 $11,245 $17 $13,167.01 $14,180 $19 $15,313.01 $16,589

$15 $11,245.01 $11,994 $19 $14,180.01 $15,193 $21 $16,589.01 $17,865

$17 $11,994.01 $12,744 $21 $15,193.01 $16,206 $24 $17,865.01 $19,141

$19 $12,744.01 $13,494 $23 $16,206.01 $17,218 $26 $19,141.01 $20,417

$20 $13,494.01 $14,243 $25 $17,218.01 $18,231 $29 $20,417.01 $21,693

$22 $14,243.01 $14,993 $27 $18,231.01 $19,244 $32 $21,693.01 $22,969

$23 $14,993.01 $15,743 $30 $19,244.01 $20,257 $35 $22,969.01 $24,245

$25 $15,743.01 $16,492 $32 $20,257.01 $21,270 $37 $24,245.01 $25,521

$27 $16,492.01 $17,242 $34 $21,270.01 $22,283 $40 $25,521.01 $26,797

$28 $17,242.01 $17,992 $36 $22,283.01 $23,296 $42 $26,797.01 $28,073

$30 $17,992.01 $18,741 $38 $23,296.01 $24,308 $45 $28,073.01 $29,349

$32 $18,741.01 $19,491 $40 $24,308.01 $25,321 $48 $29,349.01 $30,625

$33 $19,491.01 $20,241 $43 $25,321.01 $26,334 $51 $30,625.01 $31,901

$35 $20,241.01 $20,990 $45 $26,334.01 $27,347 $54 $31,901.01 $33,177

$37 $20,990.01 $21,740 $48 $27,347.01 $28,360 $57 $33,177.01 $34,453

$39 $21,740.01 $22,490 $50 $28,360.01 $29,373 $60 $34,453.01 $35,729

$41 $22,490.01 $23,239 $53 $29,373.01 $30,386 $63 $35,729.01 $37,005

$43 $23,239.01 $23,989 $55 $30,386.01 $31,398 $66 $37,005.01 $38,282

$45 $23,989.01 $24,738 $58 $31,398.01 $32,411 $70 $38,282.01 $39,558

$47 $24,738.01 $25,488 $61 $32,411.01 $33,424 $73 $39,558.01 $40,834

$49 $25,488.01 $26,238 $64 $33,424.01 $34,437 $77 $40,834.01 $42,110

$51 $26,238.01 $26,987 $66 $34,437.01 $35,450 $80 $42,110.01 $43,386

$53 $26,987.01 $27,737 $69 $35,450.01 $36,463 $84 $43,386.01 $44,662

$56 $27,737.01 $28,487 $72 $36,463.01 $37,475 $87 $44,662.01 $45,938

$58 $28,487.01 $29,236 $75 $37,475.01 $38,488 $91 $45,938.01 $47,214

$60 $29,236.01 $29,986 $78 $38,488.01 $39,501 $95 $47,214.01 $48,490

200% FPIG $25,520 $81 $39,501.01 $40,514 $99 $48,490.01 $49,766

200% FPIG $34,480 $102 $49,766.01 $51,042

200% FPIG $43,440

Weekly
Co-pay Family Size: 4
Annual Income Weekly
Co-pay Family Size: 5
Annual Income Weekly
Co-pay Family Size: 6
Annual Income

$5 Less than: $7,696 $5 Less than: $7,210 $5 Less than: $8,263

$6 $7,696.01 $9,236 $6 $7,210.01 $9,012 $7 $8,263.01 $10,328

$8 $9,236.01 $10,775 $8 $9,012.01 $10,815 $9 $10,328.01 $12,394

$10 $10,775.01 $12,314 $10 $10,815.01 $12,617 $11 $12,394.01 $14,460

$12 $12,314.01 $13,853 $12 $12,617.01 $14,420 $14 $14,460.01 $16,525

$15 $13,853.01 $15,393 $14 $14,420.01 $16,222 $17 $16,525.01 $18,591

$17 $15,393.01 $16,932 $17 $16,222.01 $18,025 $20 $18,591.01 $20,657

$20 $16,932.01 $18,471 $20 $18,025.01 $19,827 $23 $20,657.01 $22,722

$22 $18,471.01 $20,010 $23 $19,827.01 $21,629 $26 $22,722.01 $24,788

$25 $20,010.01 $21,550 $26 $21,629.01 $23,432 $30 $24,788.01 $26,853

$28 $21,550.01 $23,089 $30 $23,432.01 $25,234 $34 $26,853.01 $28,919

$32 $23,089.01 $24,628 $33 $25,234.01 $27,037 $38 $28,919.01 $30,985

$35 $24,628.01 $26,167 $37 $27,037.01 $28,839 $43 $30,985.01 $33,050

$39 $26,167.01 $27,707 $41 $28,839.01 $30,642 $47 $33,050.01 $35,116

$42 $27,707.01 $29,246 $45 $30,642.01 $32,444 $52 $35,116.01 $37,182

$45 $29,246.01 $30,785 $49 $32,444.01 $34,247 $56 $37,182.01 $39,247

$48 $30,785.01 $32,324 $53 $34,247.01 $36,049 $60 $39,247.01 $41,313

$51 $32,324.01 $33,864 $56 $36,049.01 $37,851 $64 $41,313.01 $43,379

$55 $33,864.01 $35,403 $60 $37,851.01 $39,654 $69 $43,379.01 $45,444

$58 $35,403.01 $36,942 $64 $39,654.01 $41,456 $73 $45,444.01 $47,510

$61 $36,942.01 $38,481 $68 $41,456.01 $43,259 $78 $47,510.01 $49,576

$65 $38,481.01 $40,021 $72 $43,259.01 $45,061 $83 $49,576.01 $51,641

$69 $40,021.01 $41,560 $76 $45,061.01 $46,864 $87 $51,641.01 $53,707

$72 $41,560.01 $43,099 $80 $46,864.01 $48,666 $92 $53,707.01 $55,773

$76 $43,099.01 $44,638 $85 $48,666.01 $50,469 $97 $55,773.01 $57,838

$80 $44,638.01 $46,178 $89 $50,469.01 $52,271 $102 $57,838.01 $59,904

$84 $46,178.01 $47,717 $94 $52,271.01 $54,074 $108 $59,904.01 $61,970

$88 $47,717.01 $49,256 $99 $54,074.01 $55,876 $113 $61,970.01 $64,035

$92 $49,256.01 $50,795 $103 $55,876.01 $57,678 $118 $64,035.01 $66,101

$97 $50,795.01 $52,335 $108 $57,678.01 $59,481 $124 $66,101.01 $68,166

$101 $52,335.01 $53,874 $113 $59,481.01 $61,283 $130 $68,166.01 $70,232

$105 $53,874.01 $55,413 $118 $61,283.01 $63,086 $135 $70,232.01 $72,298

$110 $55,413.01 $56,952 $123 $63,086.01 $64,888 $141 $72,298.01 $74,363

$114 $56,952.01 $58,492 $128 $64,888.01 $66,691 $147 $74,363.01 $76,429

$119 $58,492.01 $60,031 $134 $66,691.01 $68,493 $153 $76,429.01 $78,495

$124 $60,031.01 $61,570 $139 $68,493.01 $70,296 $159 $78,495.01 $80,560

200% FPIG $52,400 $145 $70,296.01 $72,098 $166 $80,560.01 $82,626

200% FPIG $61,360 200% FPIG $70,320

Weekly
Co-pay Family Size: 7
Annual Income Weekly
Co-pay Family Size: 8
Annual Income Weekly
Co-pay Family Size: 9
Annual Income

$5 Less than: $9,315 $5 Less than: $7,776 $5 Less than: $8,566

$7 $9,315.01 $11,644 $6 $7,776.01 $10,368 $6 $8,566.01 $11,421

$10 $11,644.01 $13,973 $8 $10,368.01 $12,960 $9 $11,421.01 $14,276

$13 $13,973.01 $16,302 $11 $12,960.01 $15,552 $12 $14,276.01 $17,132

$15 $16,302.01 $18,631 $14 $15,552.01 $18,144 $15 $17,132.01 $19,987

$19 $18,631.01 $20,960 $17 $18,144.01 $20,736 $19 $19,987.01 $22,842

$22 $20,960.01 $23,289 $21 $20,736.01 $23,328 $23 $22,842.01 $25,697

$26 $23,289.01 $25,617 $25 $23,328.01 $25,921 $27 $25,697.01 $28,553

$30 $25,617.01 $27,946 $29 $25,921.01 $28,513 $32 $28,553.01 $31,408

$34 $27,946.01 $30,275 $33 $28,513.01 $31,105 $36 $31,408.01 $34,263

$38 $30,275.01 $32,604 $38 $31,105.01 $33,697 $42 $34,263.01 $37,118

$43 $32,604.01 $34,933 $43 $33,697.01 $36,289 $47 $37,118.01 $39,974

$48 $34,933.01 $37,262 $48 $36,289.01 $38,881 $53 $39,974.01 $42,829

$53 $37,262.01 $39,590 $53 $38,881.01 $41,473 $59 $42,829.01 $45,684

$59 $39,590.01 $41,919 $59 $41,473.01 $44,065 $65 $45,684.01 $48,539

$63 $41,919.01 $44,248 $65 $44,065.01 $46,657 $72 $48,539.01 $51,395

$68 $44,248.01 $46,577 $70 $46,657.01 $49,249 $77 $51,395.01 $54,250

$73 $46,577.01 $48,906 $76 $49,249.01 $51,841 $83 $54,250.01 $57,105

$78 $48,906.01 $51,235 $81 $51,841.01 $54,433 $89 $57,105.01 $59,960

$83 $51,235.01 $53,564 $86 $54,433.01 $57,025 $95 $59,960.01 $62,816

$88 $53,564.01 $55,892 $92 $57,025.01 $59,617 $101 $62,816.01 $65,671

$93 $55,892.01 $58,221 $98 $59,617.01 $62,209 $108 $65,671.01 $68,526

$98 $58,221.01 $60,550 $104 $62,209.01 $64,801 $114 $68,526.01 $71,381

$104 $60,550.01 $62,879 $110 $64,801.01 $67,393 $121 $71,381.01 $74,237

$110 $62,879.01 $65,208 $116 $67,393.01 $69,985 $127 $74,237.01 $77,092

$115 $65,208.01 $67,537 $122 $69,985.01 $72,577 $134 $77,092.01 $79,947

$121 $67,537.01 $69,866 $128 $72,577.01 $75,169 $141 $79,947.01 $82,802

$127 $69,866.01 $72,194 $135 $75,169.01 $77,762 $149 $82,802.01 $85,658

$133 $72,194.01 $74,523 $142 $77,762.01 $80,354 $156 $85,658.01 $88,513

$140 $74,523.01 $76,852 $148 $80,354.01 $82,946 $164 $88,513.01 $91,368

$146 $76,852.01 $79,181 $155 $82,946.01 $85,538 $171 $91,368.01 $94,223

$153 $79,181.01 $81,510 $163 $85,538.01 $88,130 $179 $94,223.01 $97,079

$159 $81,510.01 $83,839 $170 $88,130.01 $90,722 $187 $97,079.01 $99,934

$166 $83,839.01 $86,167 $177 $90,722.01 $93,314 $195 $99,934.01 $102,789

$173 $86,167.01 $88,496 $185 $93,314.01 $95,906 $203 $102,789.01 $105,644

$180 $88,496.01 $90,825 $192 $95,906.01 $98,498 $212 $105,644.01 $108,500

$187 $90,825.01 $93,154 $200 $98,498.01 $101,090 $220 $108,500.01 $111,355

200% FPIG $79,280 $208 $101,090.01 $103,682 $229 $111,355.01 $114,210

200% FPIG $88,240 200% FPIG $97,200

Weekly
Co-pay Family Size: 10
Annual Income Weekly
Co-pay Family Size: 11
Annual Income Weekly
Co-pay Family Size: 12
Annual Income

$5 Less than: $9,355 $5 Less than: $10,145 $5 Less than: $10,935

$7 $9,355.01 $12,474 $7 $10,145.01 $13,527 $8 $10,935.01 $14,579

$10 $12,474.01 $15,592 $11 $13,527.01 $16,908 $12 $14,579.01 $18,224

$13 $15,592.01 $18,711 $14 $16,908.01 $20,290 $15 $18,224.01 $21,869

$17 $18,711.01 $21,829 $18 $20,290.01 $23,672 $20 $21,869.01 $25,514

$21 $21,829.01 $24,948 $22 $23,672.01 $27,053 $24 $25,514.01 $29,159

$25 $24,948.01 $28,066 $27 $27,053.01 $30,435 $29 $29,159.01 $32,804

$30 $28,066.01 $31,185 $32 $30,435.01 $33,817 $35 $32,804.01 $36,449

$35 $31,185.01 $34,303 $37 $33,817.01 $37,198 $40 $36,449.01 $40,093

$40 $34,303.01 $37,421 $43 $37,198.01 $40,580 $47 $40,093.01 $43,738

$45 $37,421.01 $40,540 $49 $40,580.01 $43,961 $53 $43,738.01 $47,383

$51 $40,540.01 $43,658 $56 $43,961.01 $47,343 $60 $47,383.01 $51,028

$58 $43,658.01 $46,777 $63 $47,343.01 $50,725 $67 $51,028.01 $54,673

$64 $46,777.01 $49,895 $70 $50,725.01 $54,106 $75 $54,673.01 $58,318

$71 $49,895.01 $53,014 $77 $54,106.01 $57,488 $83 $58,318.01 $61,962

$79 $53,014.01 $56,132 $85 $57,488.01 $60,870 $92 $61,962.01 $65,607

$85 $56,132.01 $59,251 $92 $60,870.01 $64,251 $99 $65,607.01 $69,252

$91 $59,251.01 $62,369 $99 $64,251.01 $67,633 $106 $69,252.01 $72,897

$97 $62,369.01 $65,487 $105 $67,633.01 $71,015 $114 $72,897.01 $76,542

$104 $65,487.01 $68,606 $113 $71,015.01 $74,396 $121 $76,542.01 $80,187

$111 $68,606.01 $71,724 $120 $74,396.01 $77,778 $129 $80,187.01 $83,832

$117 $71,724.01 $74,843 $127 $77,778.01 $81,160 $137 $83,832.01 $87,476

$125 $74,843.01 $77,961 $135 $81,160.01 $84,541 $146 $87,476.01 $91,121

$132 $77,961.01 $81,080 $143 $84,541.01 $87,923 $154 $91,121.01 $94,766

$139 $81,080.01 $84,198 $151 $87,923.01 $91,305 $163 $94,766.01 $98,411

$147 $84,198.01 $87,317 $159 $91,305.01 $94,686 $172 $98,411.01 $102,056

$154 $87,317.01 $90,435 $168 $94,686.01 $98,068 $181 $102,056.01 $105,701

$162 $90,435.01 $93,554 $176 $98,068.01 $101,450 $190 $105,701.01 $109,346

$170 $93,554.01 $96,672 $185 $101,450.01 $104,831 $199 $109,346.01 $112,990

$179 $96,672.01 $99,790 $194 $104,831.01 $108,213 $209 $112,990.01 $116,635

$187 $99,790.01 $102,909 $203 $108,213.01 $111,594 $219 $116,635.01 $120,280

$196 $102,909.01 $106,027 $212 $111,594.01 $114,976 $229 $120,280.01 $123,925

$204 $106,027.01 $109,146 $222 $114,976.01 $118,358 $239 $123,925.01 $127,570

$213 $109,146.01 $112,264 $231 $118,358.01 $121,739 $249 $127,570.01 $131,215

$222 $112,264.01 $115,383 $241 $121,739.01 $125,121 $260 $131,215.01 $134,859

$231 $115,383.01 $118,501 $251 $125,121.01 $128,503 $270 $134,859.01 $138,504

$241 $118,501.01 $121,620 $261 $128,503.01 $131,884 $281 $138,504.01 $142,149

$250 $121,620.01 $124,738 $271 $131,884.01 $135,266 $292 $142,149.01 $145,794

200% FPIG $106,160 200% FPIG $115,120 200% FPIG $124,080

Weekly
Co-pay Family Size: 13
Annual Income Weekly
Co-pay Family Size: 14
Annual Income Weekly
Co-pay Family Size: 15
Annual Income

$5 Less than: $11,724 $5 Less than: $8,343 $5 Less than: $8,869

$9 $11,724.01 $15,632 $6 $8,343.01 $12,514 $6 $8,869.01 $13,303

$12 $15,632.01 $19,540 $9 $12,514.01 $16,685 $10 $13,303.01 $17,738

$16 $19,540.01 $23,448 $13 $16,685.01 $20,856 $14 $17,738.01 $22,172

$21 $23,448.01 $27,356 $18 $20,856.01 $25,028 $19 $22,172.01 $26,607

$26 $27,356.01 $31,264 $22 $25,028.01 $29,199 $24 $26,607.01 $31,041

$31 $31,264.01 $35,172 $28 $29,199.01 $33,370 $29 $31,041.01 $35,476

$37 $35,172.01 $39,081 $33 $33,370.01 $37,541 $36 $35,476.01 $39,910

$43 $39,081.01 $42,989 $40 $37,541.01 $41,713 $42 $39,910.01 $44,345

$50 $42,989.01 $46,897 $46 $41,713.01 $45,884 $49 $44,345.01 $48,779

$57 $46,897.01 $50,805 $53 $45,884.01 $50,055 $57 $48,779.01 $53,213

$64 $50,805.01 $54,713 $61 $50,055.01 $54,226 $65 $53,213.01 $57,648

$72 $54,713.01 $58,621 $69 $54,226.01 $58,398 $73 $57,648.01 $62,082

$81 $58,621.01 $62,529 $77 $58,398.01 $62,569 $82 $62,082.01 $66,517

$89 $62,529.01 $66,437 $86 $62,569.01 $66,740 $91 $66,517.01 $70,951

$98 $66,437.01 $70,345 $95 $66,740.01 $70,911 $101 $70,951.01 $75,386

$106 $70,345.01 $74,253 $105 $70,911.01 $75,083 $112 $75,386.01 $79,820

$114 $74,253.01 $78,161 $113 $75,083.01 $79,254 $120 $79,820.01 $84,255

$122 $78,161.01 $82,069 $122 $79,254.01 $83,425 $129 $84,255.01 $88,689

$130 $82,069.01 $85,977 $130 $83,425.01 $87,596 $138 $88,689.01 $93,123

$139 $85,977.01 $89,885 $139 $87,596.01 $91,768 $148 $93,123.01 $97,558

$147 $89,885.01 $93,793 $148 $91,768.01 $95,939 $157 $97,558.01 $101,992

$156 $93,793.01 $97,701 $157 $95,939.01 $100,110 $167 $101,992.01 $106,427

$165 $97,701.01 $101,609 $167 $100,110.01 $104,281 $177 $106,427.01 $110,861

$174 $101,609.01 $105,517 $176 $104,281.01 $108,453 $187 $110,861.01 $115,296

$184 $105,517.01 $109,425 $186 $108,453.01 $112,624 $198 $115,296.01 $119,730

$194 $109,425.01 $113,333 $196 $112,624.01 $116,795 $209 $119,730.01 $124,165

$203 $113,333.01 $117,242 $207 $116,795.01 $120,966 $220 $124,165.01 $128,599

$214 $117,242.01 $121,150 $217 $120,966.01 $125,138 $231 $128,599.01 $133,034

$224 $121,150.01 $125,058 $228 $125,138.01 $129,309 $242 $133,034.01 $137,468

$234 $125,058.01 $128,966 $239 $129,309.01 $133,480 $254 $137,468.01 $141,902

$245 $128,966.01 $132,874 $250 $133,480.01 $137,651 $266 $141,902.01 $146,337

$256 $132,874.01 $136,782 $262 $137,651.01 $141,823 $278 $146,337.01 $150,771

$267 $136,782.01 $140,690 $273 $141,823.01 $145,994 $290 $150,771.01 $155,206

$278 $140,690.01 $144,598 $285 $145,994.01 $150,165 $303 $155,206.01 $159,640

$290 $144,598.01 $148,506 $297 $150,165.01 $154,336 $316 $159,640.01 $164,075

$302 $148,506.01 $152,414 $309 $154,336.01 $158,508 $329 $164,075.01 $168,509

$314 $152,414.01 $156,322 $322 $158,508.01 $162,679 $342 $168,509.01 $172,944

200% FPIG $133,040 $335 $162,679.01 $166,850 $356 $172,944.01 $177,378

200% FPIG $142,000 200% FPIG $150,960

Weekly
Co-pay Family Size: 16
Annual Income Weekly
Co-pay Family Size: 17
Annual Income Weekly
Co-pay Family Size: 18
Annual Income

$5 Less than: $9,395 $5 Less than: $9,922 $5 Less than: $10,448

$6 $9,395.01 $14,093 $7 $9,922.01 $14,883 $7 $10,448.01 $15,672

$10 $14,093.01 $18,791 $11 $14,883.01 $19,843 $12 $15,672.01 $20,896

$15 $18,791.01 $23,488 $16 $19,843.01 $24,804 $16 $20,896.01 $26,120

$20 $23,488.01 $28,186 $21 $24,804.01 $29,765 $22 $26,120.01 $31,344

$25 $28,186.01 $32,884 $27 $29,765.01 $34,726 $28 $31,344.01 $36,568

$31 $32,884.01 $37,581 $33 $34,726.01 $39,687 $35 $36,568.01 $41,792

$38 $37,581.01 $42,279 $40 $39,687.01 $44,648 $42 $41,792.01 $47,016

$45 $42,279.01 $46,977 $47 $44,648.01 $49,609 $50 $47,016.01 $52,241

$52 $46,977.01 $51,674 $55 $49,609.01 $54,569 $58 $52,241.01 $57,465

$60 $51,674.01 $56,372 $63 $54,569.01 $59,530 $67 $57,465.01 $62,689

$68 $56,372.01 $61,069 $72 $59,530.01 $64,491 $76 $62,689.01 $67,913

$77 $61,069.01 $65,767 $82 $64,491.01 $69,452 $86 $67,913.01 $73,137

$87 $65,767.01 $70,465 $92 $69,452.01 $74,413 $97 $73,137.01 $78,361

$97 $70,465.01 $75,162 $102 $74,413.01 $79,374 $108 $78,361.01 $83,585

$107 $75,162.01 $79,860 $113 $79,374.01 $84,334 $119 $83,585.01 $88,809

$118 $79,860.01 $84,558 $125 $84,334.01 $89,295 $132 $88,809.01 $94,033

$127 $84,558.01 $89,255 $135 $89,295.01 $94,256 $142 $94,033.01 $99,257

$137 $89,255.01 $93,953 $145 $94,256.01 $99,217 $152 $99,257.01 $104,481

$147 $93,953.01 $98,651 $155 $99,217.01 $104,178 $163 $104,481.01 $109,705

$156 $98,651.01 $103,348 $165 $104,178.01 $109,139 $174 $109,705.01 $114,929

$167 $103,348.01 $108,046 $176 $109,139.01 $114,100 $185 $114,929.01 $120,153

$177 $108,046.01 $112,744 $187 $114,100.01 $119,060 $197 $120,153.01 $125,377

$188 $112,744.01 $117,441 $198 $119,060.01 $124,021 $209 $125,377.01 $130,601

$199 $117,441.01 $122,139 $210 $124,021.01 $128,982 $221 $130,601.01 $135,825

$210 $122,139.01 $126,837 $221 $128,982.01 $133,943 $233 $135,825.01 $141,049

$221 $126,837.01 $131,534 $233 $133,943.01 $138,904 $246 $141,049.01 $146,273

$233 $131,534.01 $136,232 $246 $138,904.01 $143,865 $259 $146,273.01 $151,497

$245 $136,232.01 $140,930 $258 $143,865.01 $148,826 $272 $151,497.01 $156,722

$257 $140,930.01 $145,627 $271 $148,826.01 $153,786 $285 $156,722.01 $161,946

$269 $145,627.01 $150,325 $284 $153,786.01 $158,747 $299 $161,946.01 $167,170

$282 $150,325.01 $155,022 $298 $158,747.01 $163,708 $313 $167,170.01 $172,394

$295 $155,022.01 $159,720 $311 $163,708.01 $168,669 $328 $172,394.01 $177,618

$308 $159,720.01 $164,418 $325 $168,669.01 $173,630 $342 $177,618.01 $182,842

$321 $164,418.01 $169,115 $339 $173,630.01 $178,591 $357 $182,842.01 $188,066

$335 $169,115.01 $173,813 $353 $178,591.01 $183,551 $372 $188,066.01 $193,290

$349 $173,813.01 $178,511 $368 $183,551.01 $188,512 $388 $193,290.01 $198,514

$363 $178,511.01 $183,208 $383 $188,512.01 $193,473 $403 $198,514.01 $203,738

$377 $183,208.01 $187,906 $398 $193,473.01 $198,434 $419 $203,738.01 $208,962

200% FPIG $159,920 200% FPIG $168,880 200% FPIG $177,840

Weekly
Co-pay Family Size: 19
Annual Income Weekly
Co-pay Family Size: 20
Annual Income Weekly
Co-pay Family Size: 21
Annual Income

$5 Less than: $10,975 $5 Less than: $11,501 $5 Less than: $12,027

$7 $10,975.01 $16,462 $8 $11,501.01 $17,251 $8 $12,027.01 $18,041

$12 $16,462.01 $21,949 $13 $17,251.01 $23,002 $13 $18,041.01 $24,055

$17 $21,949.01 $27,436 $18 $23,002.01 $28,752 $19 $24,055.01 $30,068

$23 $27,436.01 $32,924 $24 $28,752.01 $34,503 $25 $30,068.01 $36,082

$29 $32,924.01 $38,411 $31 $34,503.01 $40,253 $32 $36,082.01 $42,096

$36 $38,411.01 $43,898 $38 $40,253.01 $46,004 $40 $42,096.01 $48,109

$44 $43,898.01 $49,385 $46 $46,004.01 $51,754 $48 $48,109.01 $54,123

$52 $49,385.01 $54,873 $55 $51,754.01 $57,505 $57 $54,123.01 $60,137

$61 $54,873.01 $60,360 $64 $57,505.01 $63,255 $67 $60,137.01 $66,150

$70 $60,360.01 $65,847 $73 $63,255.01 $69,005 $77 $66,150.01 $72,164

$80 $65,847.01 $71,334 $84 $69,005.01 $74,756 $88 $72,164.01 $78,177

$90 $71,334.01 $76,822 $95 $74,756.01 $80,506 $99 $78,177.01 $84,191

$102 $76,822.01 $82,309 $106 $80,506.01 $86,257 $111 $84,191.01 $90,205

$113 $82,309.01 $87,796 $119 $86,257.01 $92,007 $124 $90,205.01 $96,218

$125 $87,796.01 $93,283 $131 $92,007.01 $97,758 $137 $96,218.01 $102,232

$138 $93,283.01 $98,771 $145 $97,758.01 $103,508 $151 $102,232.01 $108,246

$149 $98,771.01 $104,258 $156 $103,508.01 $109,259 $163 $108,246.01 $114,259

$160 $104,258.01 $109,745 $168 $109,259.01 $115,009 $175 $114,259.01 $120,273

$171 $109,745.01 $115,232 $179 $115,009.01 $120,759 $188 $120,273.01 $126,287

$183 $115,232.01 $120,720 $191 $120,759.01 $126,510 $200 $126,287.01 $132,300

$195 $120,720.01 $126,207 $204 $126,510.01 $132,260 $213 $132,300.01 $138,314

$207 $126,207.01 $131,694 $217 $132,260.01 $138,011 $227 $138,314.01 $144,328

$219 $131,694.01 $137,181 $230 $138,011.01 $143,761 $240 $144,328.01 $150,341

$232 $137,181.01 $142,669 $243 $143,761.01 $149,512 $254 $150,341.01 $156,355

$245 $142,669.01 $148,156 $257 $149,512.01 $155,262 $268 $156,355.01 $162,369

$258 $148,156.01 $153,643 $271 $155,262.01 $161,013 $283 $162,369.01 $168,382

$272 $153,643.01 $159,130 $285 $161,013.01 $166,763 $298 $168,382.01 $174,396

$286 $159,130.01 $164,618 $299 $166,763.01 $172,514 $313 $174,396.01 $180,410

$300 $164,618.01 $170,105 $314 $172,514.01 $178,264 $329 $180,410.01 $186,423

$314 $170,105.01 $175,592 $329 $178,264.01 $184,014 $344 $186,423.01 $192,437

$329 $175,592.01 $181,079 $345 $184,014.01 $189,765 $361 $192,437.01 $198,450

$344 $181,079.01 $186,567 $361 $189,765.01 $195,515 $377 $198,450.01 $204,464

$359 $186,567.01 $192,054 $377 $195,515.01 $201,266 $394 $204,464.01 $210,478

$375 $192,054.01 $197,541 $393 $201,266.01 $207,016 $411 $210,478.01 $216,491

$391 $197,541.01 $203,028 $410 $207,016.01 $212,767 $428 $216,491.01 $222,505

$407 $203,028.01 $208,516 $427 $212,767.01 $218,517 $446 $222,505.01 $228,519

$424 $208,516.01 $214,003 $444 $218,517.01 $224,268 $464 $228,519.01 $234,532

$440 $214,003.01 $219,490 $461 $224,268.01 $230,018 $483 $234,532.01 $240,546

200% FPIG $186,800 200% FPIG $195,760 200% FPIG $204,720

APPENDIX C

STEPPARENT DEDUCTION CHART

County of residence Family composition/size

2 3 4 5 6 Each additional person

Adams, Allegheny, Berks, Blair, Bradford, Butler, Centre, Columbia, Crawford, Cumberland, Dauphin, Delaware, Erie, Lackawanna, Lebanon, Lehigh, Luzerne, Lycoming, Monroe, Montour, Northampton, Philadelphia, Sullivan, Susquehanna, Union, Warren, Wayne, Westmoreland, Wyoming and York $461 $587 $724 $859 $976 $121

Armstrong, Bedford, Cambria, Clarion, Clearfield, Fayette, Forest, Fulton, Greene, Huntingdon, Jefferson, Juniata, Northumberland, Schuylkill and Somerset $406 $532 $662 $791 $894 $121

Beaver, Cameron, Carbon, Clinton, Elk, Franklin, Indiana, Lawrence, McKean, Mercer, Mifflin, Perry, Potter, Snyder, Tioga, Venango and Washington $444 $573 $698 $829 $943 $121

Bucks, Chester, Lancaster, Montgomery and Pike $481 $614 $749 $885 $1,001 $121

[Pa.B. Doc. No. 20-1570. Filed for public inspection November 13, 2020, 9:00 a.m.]

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Weekly Co-pay	Family Size: 1 Annual Income		Weekly Co-pay	Family Size: 2 Annual Income		Weekly Co-pay	Family Size: 3 Annual Income
$5	Less than:	$5,997	$5	Less than:	$7,090	$5	Less than:	$7,656
$6	$5,997.01	$6,747	$7	$7,090.01	$8,103	$7	$7,656.01	$8,932
$7	$6,747.01	$7,497	$8	$8,103.01	$9,116	$8	$8,932.01	$10,208
$8	$7,497.01	$8,246	$10	$9,116.01	$10,129	$10	$10,208.01	$11,484
$10	$8,246.01	$8,996	$11	$10,129.01	$11,141	$12	$11,484.01	$12,761
$11	$8,996.01	$9,745	$13	$11,141.01	$12,154	$14	$12,761.01	$14,037
$12	$9,745.01	$10,495	$15	$12,154.01	$13,167	$16	$14,037.01	$15,313
$14	$10,495.01	$11,245	$17	$13,167.01	$14,180	$19	$15,313.01	$16,589
$15	$11,245.01	$11,994	$19	$14,180.01	$15,193	$21	$16,589.01	$17,865
$17	$11,994.01	$12,744	$21	$15,193.01	$16,206	$24	$17,865.01	$19,141
$19	$12,744.01	$13,494	$23	$16,206.01	$17,218	$26	$19,141.01	$20,417
$20	$13,494.01	$14,243	$25	$17,218.01	$18,231	$29	$20,417.01	$21,693
$22	$14,243.01	$14,993	$27	$18,231.01	$19,244	$32	$21,693.01	$22,969
$23	$14,993.01	$15,743	$30	$19,244.01	$20,257	$35	$22,969.01	$24,245
$25	$15,743.01	$16,492	$32	$20,257.01	$21,270	$37	$24,245.01	$25,521
$27	$16,492.01	$17,242	$34	$21,270.01	$22,283	$40	$25,521.01	$26,797
$28	$17,242.01	$17,992	$36	$22,283.01	$23,296	$42	$26,797.01	$28,073
$30	$17,992.01	$18,741	$38	$23,296.01	$24,308	$45	$28,073.01	$29,349
$32	$18,741.01	$19,491	$40	$24,308.01	$25,321	$48	$29,349.01	$30,625
$33	$19,491.01	$20,241	$43	$25,321.01	$26,334	$51	$30,625.01	$31,901
$35	$20,241.01	$20,990	$45	$26,334.01	$27,347	$54	$31,901.01	$33,177
$37	$20,990.01	$21,740	$48	$27,347.01	$28,360	$57	$33,177.01	$34,453
$39	$21,740.01	$22,490	$50	$28,360.01	$29,373	$60	$34,453.01	$35,729
$41	$22,490.01	$23,239	$53	$29,373.01	$30,386	$63	$35,729.01	$37,005
$43	$23,239.01	$23,989	$55	$30,386.01	$31,398	$66	$37,005.01	$38,282
$45	$23,989.01	$24,738	$58	$31,398.01	$32,411	$70	$38,282.01	$39,558
$47	$24,738.01	$25,488	$61	$32,411.01	$33,424	$73	$39,558.01	$40,834
$49	$25,488.01	$26,238	$64	$33,424.01	$34,437	$77	$40,834.01	$42,110
$51	$26,238.01	$26,987	$66	$34,437.01	$35,450	$80	$42,110.01	$43,386
$53	$26,987.01	$27,737	$69	$35,450.01	$36,463	$84	$43,386.01	$44,662
$56	$27,737.01	$28,487	$72	$36,463.01	$37,475	$87	$44,662.01	$45,938
$58	$28,487.01	$29,236	$75	$37,475.01	$38,488	$91	$45,938.01	$47,214
$60	$29,236.01	$29,986	$78	$38,488.01	$39,501	$95	$47,214.01	$48,490
	200% FPIG	$25,520	$81	$39,501.01	$40,514	$99	$48,490.01	$49,766
				200% FPIG	$34,480	$102	$49,766.01	$51,042
							200% FPIG	$43,440

Weekly Co-pay	Family Size: 4 Annual Income		Weekly Co-pay	Family Size: 5 Annual Income		Weekly Co-pay	Family Size: 6 Annual Income
$5	Less than:	$7,696	$5	Less than:	$7,210	$5	Less than:	$8,263
$6	$7,696.01	$9,236	$6	$7,210.01	$9,012	$7	$8,263.01	$10,328
$8	$9,236.01	$10,775	$8	$9,012.01	$10,815	$9	$10,328.01	$12,394
$10	$10,775.01	$12,314	$10	$10,815.01	$12,617	$11	$12,394.01	$14,460
$12	$12,314.01	$13,853	$12	$12,617.01	$14,420	$14	$14,460.01	$16,525
$15	$13,853.01	$15,393	$14	$14,420.01	$16,222	$17	$16,525.01	$18,591
$17	$15,393.01	$16,932	$17	$16,222.01	$18,025	$20	$18,591.01	$20,657
$20	$16,932.01	$18,471	$20	$18,025.01	$19,827	$23	$20,657.01	$22,722
$22	$18,471.01	$20,010	$23	$19,827.01	$21,629	$26	$22,722.01	$24,788
$25	$20,010.01	$21,550	$26	$21,629.01	$23,432	$30	$24,788.01	$26,853
$28	$21,550.01	$23,089	$30	$23,432.01	$25,234	$34	$26,853.01	$28,919
$32	$23,089.01	$24,628	$33	$25,234.01	$27,037	$38	$28,919.01	$30,985
$35	$24,628.01	$26,167	$37	$27,037.01	$28,839	$43	$30,985.01	$33,050
$39	$26,167.01	$27,707	$41	$28,839.01	$30,642	$47	$33,050.01	$35,116
$42	$27,707.01	$29,246	$45	$30,642.01	$32,444	$52	$35,116.01	$37,182
$45	$29,246.01	$30,785	$49	$32,444.01	$34,247	$56	$37,182.01	$39,247
$48	$30,785.01	$32,324	$53	$34,247.01	$36,049	$60	$39,247.01	$41,313
$51	$32,324.01	$33,864	$56	$36,049.01	$37,851	$64	$41,313.01	$43,379
$55	$33,864.01	$35,403	$60	$37,851.01	$39,654	$69	$43,379.01	$45,444
$58	$35,403.01	$36,942	$64	$39,654.01	$41,456	$73	$45,444.01	$47,510
$61	$36,942.01	$38,481	$68	$41,456.01	$43,259	$78	$47,510.01	$49,576
$65	$38,481.01	$40,021	$72	$43,259.01	$45,061	$83	$49,576.01	$51,641
$69	$40,021.01	$41,560	$76	$45,061.01	$46,864	$87	$51,641.01	$53,707
$72	$41,560.01	$43,099	$80	$46,864.01	$48,666	$92	$53,707.01	$55,773
$76	$43,099.01	$44,638	$85	$48,666.01	$50,469	$97	$55,773.01	$57,838
$80	$44,638.01	$46,178	$89	$50,469.01	$52,271	$102	$57,838.01	$59,904
$84	$46,178.01	$47,717	$94	$52,271.01	$54,074	$108	$59,904.01	$61,970
$88	$47,717.01	$49,256	$99	$54,074.01	$55,876	$113	$61,970.01	$64,035
$92	$49,256.01	$50,795	$103	$55,876.01	$57,678	$118	$64,035.01	$66,101
$97	$50,795.01	$52,335	$108	$57,678.01	$59,481	$124	$66,101.01	$68,166
$101	$52,335.01	$53,874	$113	$59,481.01	$61,283	$130	$68,166.01	$70,232
$105	$53,874.01	$55,413	$118	$61,283.01	$63,086	$135	$70,232.01	$72,298
$110	$55,413.01	$56,952	$123	$63,086.01	$64,888	$141	$72,298.01	$74,363
$114	$56,952.01	$58,492	$128	$64,888.01	$66,691	$147	$74,363.01	$76,429
$119	$58,492.01	$60,031	$134	$66,691.01	$68,493	$153	$76,429.01	$78,495
$124	$60,031.01	$61,570	$139	$68,493.01	$70,296	$159	$78,495.01	$80,560
	200% FPIG	$52,400	$145	$70,296.01	$72,098	$166	$80,560.01	$82,626
				200% FPIG	$61,360		200% FPIG	$70,320

Weekly Co-pay	Family Size: 7 Annual Income		Weekly Co-pay	Family Size: 8 Annual Income		Weekly Co-pay	Family Size: 9 Annual Income
$5	Less than:	$9,315	$5	Less than:	$7,776	$5	Less than:	$8,566
$7	$9,315.01	$11,644	$6	$7,776.01	$10,368	$6	$8,566.01	$11,421
$10	$11,644.01	$13,973	$8	$10,368.01	$12,960	$9	$11,421.01	$14,276
$13	$13,973.01	$16,302	$11	$12,960.01	$15,552	$12	$14,276.01	$17,132
$15	$16,302.01	$18,631	$14	$15,552.01	$18,144	$15	$17,132.01	$19,987
$19	$18,631.01	$20,960	$17	$18,144.01	$20,736	$19	$19,987.01	$22,842
$22	$20,960.01	$23,289	$21	$20,736.01	$23,328	$23	$22,842.01	$25,697
$26	$23,289.01	$25,617	$25	$23,328.01	$25,921	$27	$25,697.01	$28,553
$30	$25,617.01	$27,946	$29	$25,921.01	$28,513	$32	$28,553.01	$31,408
$34	$27,946.01	$30,275	$33	$28,513.01	$31,105	$36	$31,408.01	$34,263
$38	$30,275.01	$32,604	$38	$31,105.01	$33,697	$42	$34,263.01	$37,118
$43	$32,604.01	$34,933	$43	$33,697.01	$36,289	$47	$37,118.01	$39,974
$48	$34,933.01	$37,262	$48	$36,289.01	$38,881	$53	$39,974.01	$42,829
$53	$37,262.01	$39,590	$53	$38,881.01	$41,473	$59	$42,829.01	$45,684
$59	$39,590.01	$41,919	$59	$41,473.01	$44,065	$65	$45,684.01	$48,539
$63	$41,919.01	$44,248	$65	$44,065.01	$46,657	$72	$48,539.01	$51,395
$68	$44,248.01	$46,577	$70	$46,657.01	$49,249	$77	$51,395.01	$54,250
$73	$46,577.01	$48,906	$76	$49,249.01	$51,841	$83	$54,250.01	$57,105
$78	$48,906.01	$51,235	$81	$51,841.01	$54,433	$89	$57,105.01	$59,960
$83	$51,235.01	$53,564	$86	$54,433.01	$57,025	$95	$59,960.01	$62,816
$88	$53,564.01	$55,892	$92	$57,025.01	$59,617	$101	$62,816.01	$65,671
$93	$55,892.01	$58,221	$98	$59,617.01	$62,209	$108	$65,671.01	$68,526
$98	$58,221.01	$60,550	$104	$62,209.01	$64,801	$114	$68,526.01	$71,381
$104	$60,550.01	$62,879	$110	$64,801.01	$67,393	$121	$71,381.01	$74,237
$110	$62,879.01	$65,208	$116	$67,393.01	$69,985	$127	$74,237.01	$77,092
$115	$65,208.01	$67,537	$122	$69,985.01	$72,577	$134	$77,092.01	$79,947
$121	$67,537.01	$69,866	$128	$72,577.01	$75,169	$141	$79,947.01	$82,802
$127	$69,866.01	$72,194	$135	$75,169.01	$77,762	$149	$82,802.01	$85,658
$133	$72,194.01	$74,523	$142	$77,762.01	$80,354	$156	$85,658.01	$88,513
$140	$74,523.01	$76,852	$148	$80,354.01	$82,946	$164	$88,513.01	$91,368
$146	$76,852.01	$79,181	$155	$82,946.01	$85,538	$171	$91,368.01	$94,223
$153	$79,181.01	$81,510	$163	$85,538.01	$88,130	$179	$94,223.01	$97,079
$159	$81,510.01	$83,839	$170	$88,130.01	$90,722	$187	$97,079.01	$99,934
$166	$83,839.01	$86,167	$177	$90,722.01	$93,314	$195	$99,934.01	$102,789
$173	$86,167.01	$88,496	$185	$93,314.01	$95,906	$203	$102,789.01	$105,644
$180	$88,496.01	$90,825	$192	$95,906.01	$98,498	$212	$105,644.01	$108,500
$187	$90,825.01	$93,154	$200	$98,498.01	$101,090	$220	$108,500.01	$111,355
	200% FPIG	$79,280	$208	$101,090.01	$103,682	$229	$111,355.01	$114,210
				200% FPIG	$88,240		200% FPIG	$97,200

Weekly Co-pay	Family Size: 10 Annual Income		Weekly Co-pay	Family Size: 11 Annual Income		Weekly Co-pay	Family Size: 12 Annual Income
$5	Less than:	$9,355	$5	Less than:	$10,145	$5	Less than:	$10,935
$7	$9,355.01	$12,474	$7	$10,145.01	$13,527	$8	$10,935.01	$14,579
$10	$12,474.01	$15,592	$11	$13,527.01	$16,908	$12	$14,579.01	$18,224
$13	$15,592.01	$18,711	$14	$16,908.01	$20,290	$15	$18,224.01	$21,869
$17	$18,711.01	$21,829	$18	$20,290.01	$23,672	$20	$21,869.01	$25,514
$21	$21,829.01	$24,948	$22	$23,672.01	$27,053	$24	$25,514.01	$29,159
$25	$24,948.01	$28,066	$27	$27,053.01	$30,435	$29	$29,159.01	$32,804
$30	$28,066.01	$31,185	$32	$30,435.01	$33,817	$35	$32,804.01	$36,449
$35	$31,185.01	$34,303	$37	$33,817.01	$37,198	$40	$36,449.01	$40,093
$40	$34,303.01	$37,421	$43	$37,198.01	$40,580	$47	$40,093.01	$43,738
$45	$37,421.01	$40,540	$49	$40,580.01	$43,961	$53	$43,738.01	$47,383
$51	$40,540.01	$43,658	$56	$43,961.01	$47,343	$60	$47,383.01	$51,028
$58	$43,658.01	$46,777	$63	$47,343.01	$50,725	$67	$51,028.01	$54,673
$64	$46,777.01	$49,895	$70	$50,725.01	$54,106	$75	$54,673.01	$58,318
$71	$49,895.01	$53,014	$77	$54,106.01	$57,488	$83	$58,318.01	$61,962
$79	$53,014.01	$56,132	$85	$57,488.01	$60,870	$92	$61,962.01	$65,607
$85	$56,132.01	$59,251	$92	$60,870.01	$64,251	$99	$65,607.01	$69,252
$91	$59,251.01	$62,369	$99	$64,251.01	$67,633	$106	$69,252.01	$72,897
$97	$62,369.01	$65,487	$105	$67,633.01	$71,015	$114	$72,897.01	$76,542
$104	$65,487.01	$68,606	$113	$71,015.01	$74,396	$121	$76,542.01	$80,187
$111	$68,606.01	$71,724	$120	$74,396.01	$77,778	$129	$80,187.01	$83,832
$117	$71,724.01	$74,843	$127	$77,778.01	$81,160	$137	$83,832.01	$87,476
$125	$74,843.01	$77,961	$135	$81,160.01	$84,541	$146	$87,476.01	$91,121
$132	$77,961.01	$81,080	$143	$84,541.01	$87,923	$154	$91,121.01	$94,766
$139	$81,080.01	$84,198	$151	$87,923.01	$91,305	$163	$94,766.01	$98,411
$147	$84,198.01	$87,317	$159	$91,305.01	$94,686	$172	$98,411.01	$102,056
$154	$87,317.01	$90,435	$168	$94,686.01	$98,068	$181	$102,056.01	$105,701
$162	$90,435.01	$93,554	$176	$98,068.01	$101,450	$190	$105,701.01	$109,346
$170	$93,554.01	$96,672	$185	$101,450.01	$104,831	$199	$109,346.01	$112,990
$179	$96,672.01	$99,790	$194	$104,831.01	$108,213	$209	$112,990.01	$116,635
$187	$99,790.01	$102,909	$203	$108,213.01	$111,594	$219	$116,635.01	$120,280
$196	$102,909.01	$106,027	$212	$111,594.01	$114,976	$229	$120,280.01	$123,925
$204	$106,027.01	$109,146	$222	$114,976.01	$118,358	$239	$123,925.01	$127,570
$213	$109,146.01	$112,264	$231	$118,358.01	$121,739	$249	$127,570.01	$131,215
$222	$112,264.01	$115,383	$241	$121,739.01	$125,121	$260	$131,215.01	$134,859
$231	$115,383.01	$118,501	$251	$125,121.01	$128,503	$270	$134,859.01	$138,504
$241	$118,501.01	$121,620	$261	$128,503.01	$131,884	$281	$138,504.01	$142,149
$250	$121,620.01	$124,738	$271	$131,884.01	$135,266	$292	$142,149.01	$145,794
	200% FPIG	$106,160		200% FPIG	$115,120		200% FPIG	$124,080

Weekly Co-pay	Family Size: 13 Annual Income		Weekly Co-pay	Family Size: 14 Annual Income		Weekly Co-pay	Family Size: 15 Annual Income
$5	Less than:	$11,724	$5	Less than:	$8,343	$5	Less than:	$8,869
$9	$11,724.01	$15,632	$6	$8,343.01	$12,514	$6	$8,869.01	$13,303
$12	$15,632.01	$19,540	$9	$12,514.01	$16,685	$10	$13,303.01	$17,738
$16	$19,540.01	$23,448	$13	$16,685.01	$20,856	$14	$17,738.01	$22,172
$21	$23,448.01	$27,356	$18	$20,856.01	$25,028	$19	$22,172.01	$26,607
$26	$27,356.01	$31,264	$22	$25,028.01	$29,199	$24	$26,607.01	$31,041
$31	$31,264.01	$35,172	$28	$29,199.01	$33,370	$29	$31,041.01	$35,476
$37	$35,172.01	$39,081	$33	$33,370.01	$37,541	$36	$35,476.01	$39,910
$43	$39,081.01	$42,989	$40	$37,541.01	$41,713	$42	$39,910.01	$44,345
$50	$42,989.01	$46,897	$46	$41,713.01	$45,884	$49	$44,345.01	$48,779
$57	$46,897.01	$50,805	$53	$45,884.01	$50,055	$57	$48,779.01	$53,213
$64	$50,805.01	$54,713	$61	$50,055.01	$54,226	$65	$53,213.01	$57,648
$72	$54,713.01	$58,621	$69	$54,226.01	$58,398	$73	$57,648.01	$62,082
$81	$58,621.01	$62,529	$77	$58,398.01	$62,569	$82	$62,082.01	$66,517
$89	$62,529.01	$66,437	$86	$62,569.01	$66,740	$91	$66,517.01	$70,951
$98	$66,437.01	$70,345	$95	$66,740.01	$70,911	$101	$70,951.01	$75,386
$106	$70,345.01	$74,253	$105	$70,911.01	$75,083	$112	$75,386.01	$79,820
$114	$74,253.01	$78,161	$113	$75,083.01	$79,254	$120	$79,820.01	$84,255
$122	$78,161.01	$82,069	$122	$79,254.01	$83,425	$129	$84,255.01	$88,689
$130	$82,069.01	$85,977	$130	$83,425.01	$87,596	$138	$88,689.01	$93,123
$139	$85,977.01	$89,885	$139	$87,596.01	$91,768	$148	$93,123.01	$97,558
$147	$89,885.01	$93,793	$148	$91,768.01	$95,939	$157	$97,558.01	$101,992
$156	$93,793.01	$97,701	$157	$95,939.01	$100,110	$167	$101,992.01	$106,427
$165	$97,701.01	$101,609	$167	$100,110.01	$104,281	$177	$106,427.01	$110,861
$174	$101,609.01	$105,517	$176	$104,281.01	$108,453	$187	$110,861.01	$115,296
$184	$105,517.01	$109,425	$186	$108,453.01	$112,624	$198	$115,296.01	$119,730
$194	$109,425.01	$113,333	$196	$112,624.01	$116,795	$209	$119,730.01	$124,165
$203	$113,333.01	$117,242	$207	$116,795.01	$120,966	$220	$124,165.01	$128,599
$214	$117,242.01	$121,150	$217	$120,966.01	$125,138	$231	$128,599.01	$133,034
$224	$121,150.01	$125,058	$228	$125,138.01	$129,309	$242	$133,034.01	$137,468
$234	$125,058.01	$128,966	$239	$129,309.01	$133,480	$254	$137,468.01	$141,902
$245	$128,966.01	$132,874	$250	$133,480.01	$137,651	$266	$141,902.01	$146,337
$256	$132,874.01	$136,782	$262	$137,651.01	$141,823	$278	$146,337.01	$150,771
$267	$136,782.01	$140,690	$273	$141,823.01	$145,994	$290	$150,771.01	$155,206
$278	$140,690.01	$144,598	$285	$145,994.01	$150,165	$303	$155,206.01	$159,640
$290	$144,598.01	$148,506	$297	$150,165.01	$154,336	$316	$159,640.01	$164,075
$302	$148,506.01	$152,414	$309	$154,336.01	$158,508	$329	$164,075.01	$168,509
$314	$152,414.01	$156,322	$322	$158,508.01	$162,679	$342	$168,509.01	$172,944
	200% FPIG	$133,040	$335	$162,679.01	$166,850	$356	$172,944.01	$177,378
				200% FPIG	$142,000		200% FPIG	$150,960

Weekly Co-pay	Family Size: 16 Annual Income		Weekly Co-pay	Family Size: 17 Annual Income		Weekly Co-pay	Family Size: 18 Annual Income
$5	Less than:	$9,395	$5	Less than:	$9,922	$5	Less than:	$10,448
$6	$9,395.01	$14,093	$7	$9,922.01	$14,883	$7	$10,448.01	$15,672
$10	$14,093.01	$18,791	$11	$14,883.01	$19,843	$12	$15,672.01	$20,896
$15	$18,791.01	$23,488	$16	$19,843.01	$24,804	$16	$20,896.01	$26,120
$20	$23,488.01	$28,186	$21	$24,804.01	$29,765	$22	$26,120.01	$31,344
$25	$28,186.01	$32,884	$27	$29,765.01	$34,726	$28	$31,344.01	$36,568
$31	$32,884.01	$37,581	$33	$34,726.01	$39,687	$35	$36,568.01	$41,792
$38	$37,581.01	$42,279	$40	$39,687.01	$44,648	$42	$41,792.01	$47,016
$45	$42,279.01	$46,977	$47	$44,648.01	$49,609	$50	$47,016.01	$52,241
$52	$46,977.01	$51,674	$55	$49,609.01	$54,569	$58	$52,241.01	$57,465
$60	$51,674.01	$56,372	$63	$54,569.01	$59,530	$67	$57,465.01	$62,689
$68	$56,372.01	$61,069	$72	$59,530.01	$64,491	$76	$62,689.01	$67,913
$77	$61,069.01	$65,767	$82	$64,491.01	$69,452	$86	$67,913.01	$73,137
$87	$65,767.01	$70,465	$92	$69,452.01	$74,413	$97	$73,137.01	$78,361
$97	$70,465.01	$75,162	$102	$74,413.01	$79,374	$108	$78,361.01	$83,585
$107	$75,162.01	$79,860	$113	$79,374.01	$84,334	$119	$83,585.01	$88,809
$118	$79,860.01	$84,558	$125	$84,334.01	$89,295	$132	$88,809.01	$94,033
$127	$84,558.01	$89,255	$135	$89,295.01	$94,256	$142	$94,033.01	$99,257
$137	$89,255.01	$93,953	$145	$94,256.01	$99,217	$152	$99,257.01	$104,481
$147	$93,953.01	$98,651	$155	$99,217.01	$104,178	$163	$104,481.01	$109,705
$156	$98,651.01	$103,348	$165	$104,178.01	$109,139	$174	$109,705.01	$114,929
$167	$103,348.01	$108,046	$176	$109,139.01	$114,100	$185	$114,929.01	$120,153
$177	$108,046.01	$112,744	$187	$114,100.01	$119,060	$197	$120,153.01	$125,377
$188	$112,744.01	$117,441	$198	$119,060.01	$124,021	$209	$125,377.01	$130,601
$199	$117,441.01	$122,139	$210	$124,021.01	$128,982	$221	$130,601.01	$135,825
$210	$122,139.01	$126,837	$221	$128,982.01	$133,943	$233	$135,825.01	$141,049
$221	$126,837.01	$131,534	$233	$133,943.01	$138,904	$246	$141,049.01	$146,273
$233	$131,534.01	$136,232	$246	$138,904.01	$143,865	$259	$146,273.01	$151,497
$245	$136,232.01	$140,930	$258	$143,865.01	$148,826	$272	$151,497.01	$156,722
$257	$140,930.01	$145,627	$271	$148,826.01	$153,786	$285	$156,722.01	$161,946
$269	$145,627.01	$150,325	$284	$153,786.01	$158,747	$299	$161,946.01	$167,170
$282	$150,325.01	$155,022	$298	$158,747.01	$163,708	$313	$167,170.01	$172,394
$295	$155,022.01	$159,720	$311	$163,708.01	$168,669	$328	$172,394.01	$177,618
$308	$159,720.01	$164,418	$325	$168,669.01	$173,630	$342	$177,618.01	$182,842
$321	$164,418.01	$169,115	$339	$173,630.01	$178,591	$357	$182,842.01	$188,066
$335	$169,115.01	$173,813	$353	$178,591.01	$183,551	$372	$188,066.01	$193,290
$349	$173,813.01	$178,511	$368	$183,551.01	$188,512	$388	$193,290.01	$198,514
$363	$178,511.01	$183,208	$383	$188,512.01	$193,473	$403	$198,514.01	$203,738
$377	$183,208.01	$187,906	$398	$193,473.01	$198,434	$419	$203,738.01	$208,962
	200% FPIG	$159,920		200% FPIG	$168,880		200% FPIG	$177,840

Weekly Co-pay	Family Size: 19 Annual Income		Weekly Co-pay	Family Size: 20 Annual Income		Weekly Co-pay	Family Size: 21 Annual Income
$5	Less than:	$10,975	$5	Less than:	$11,501	$5	Less than:	$12,027
$7	$10,975.01	$16,462	$8	$11,501.01	$17,251	$8	$12,027.01	$18,041
$12	$16,462.01	$21,949	$13	$17,251.01	$23,002	$13	$18,041.01	$24,055
$17	$21,949.01	$27,436	$18	$23,002.01	$28,752	$19	$24,055.01	$30,068
$23	$27,436.01	$32,924	$24	$28,752.01	$34,503	$25	$30,068.01	$36,082
$29	$32,924.01	$38,411	$31	$34,503.01	$40,253	$32	$36,082.01	$42,096
$36	$38,411.01	$43,898	$38	$40,253.01	$46,004	$40	$42,096.01	$48,109
$44	$43,898.01	$49,385	$46	$46,004.01	$51,754	$48	$48,109.01	$54,123
$52	$49,385.01	$54,873	$55	$51,754.01	$57,505	$57	$54,123.01	$60,137
$61	$54,873.01	$60,360	$64	$57,505.01	$63,255	$67	$60,137.01	$66,150
$70	$60,360.01	$65,847	$73	$63,255.01	$69,005	$77	$66,150.01	$72,164
$80	$65,847.01	$71,334	$84	$69,005.01	$74,756	$88	$72,164.01	$78,177
$90	$71,334.01	$76,822	$95	$74,756.01	$80,506	$99	$78,177.01	$84,191
$102	$76,822.01	$82,309	$106	$80,506.01	$86,257	$111	$84,191.01	$90,205
$113	$82,309.01	$87,796	$119	$86,257.01	$92,007	$124	$90,205.01	$96,218
$125	$87,796.01	$93,283	$131	$92,007.01	$97,758	$137	$96,218.01	$102,232
$138	$93,283.01	$98,771	$145	$97,758.01	$103,508	$151	$102,232.01	$108,246
$149	$98,771.01	$104,258	$156	$103,508.01	$109,259	$163	$108,246.01	$114,259
$160	$104,258.01	$109,745	$168	$109,259.01	$115,009	$175	$114,259.01	$120,273
$171	$109,745.01	$115,232	$179	$115,009.01	$120,759	$188	$120,273.01	$126,287
$183	$115,232.01	$120,720	$191	$120,759.01	$126,510	$200	$126,287.01	$132,300
$195	$120,720.01	$126,207	$204	$126,510.01	$132,260	$213	$132,300.01	$138,314
$207	$126,207.01	$131,694	$217	$132,260.01	$138,011	$227	$138,314.01	$144,328
$219	$131,694.01	$137,181	$230	$138,011.01	$143,761	$240	$144,328.01	$150,341
$232	$137,181.01	$142,669	$243	$143,761.01	$149,512	$254	$150,341.01	$156,355
$245	$142,669.01	$148,156	$257	$149,512.01	$155,262	$268	$156,355.01	$162,369
$258	$148,156.01	$153,643	$271	$155,262.01	$161,013	$283	$162,369.01	$168,382
$272	$153,643.01	$159,130	$285	$161,013.01	$166,763	$298	$168,382.01	$174,396
$286	$159,130.01	$164,618	$299	$166,763.01	$172,514	$313	$174,396.01	$180,410
$300	$164,618.01	$170,105	$314	$172,514.01	$178,264	$329	$180,410.01	$186,423
$314	$170,105.01	$175,592	$329	$178,264.01	$184,014	$344	$186,423.01	$192,437
$329	$175,592.01	$181,079	$345	$184,014.01	$189,765	$361	$192,437.01	$198,450
$344	$181,079.01	$186,567	$361	$189,765.01	$195,515	$377	$198,450.01	$204,464
$359	$186,567.01	$192,054	$377	$195,515.01	$201,266	$394	$204,464.01	$210,478
$375	$192,054.01	$197,541	$393	$201,266.01	$207,016	$411	$210,478.01	$216,491
$391	$197,541.01	$203,028	$410	$207,016.01	$212,767	$428	$216,491.01	$222,505
$407	$203,028.01	$208,516	$427	$212,767.01	$218,517	$446	$222,505.01	$228,519
$424	$208,516.01	$214,003	$444	$218,517.01	$224,268	$464	$228,519.01	$234,532
$440	$214,003.01	$219,490	$461	$224,268.01	$230,018	$483	$234,532.01	$240,546
	200% FPIG	$186,800		200% FPIG	$195,760		200% FPIG	$204,720

County of residence	Family composition/size
	2	3	4	5	6	Each additional person
Adams, Allegheny, Berks, Blair, Bradford, Butler, Centre, Columbia, Crawford, Cumberland, Dauphin, Delaware, Erie, Lackawanna, Lebanon, Lehigh, Luzerne, Lycoming, Monroe, Montour, Northampton, Philadelphia, Sullivan, Susquehanna, Union, Warren, Wayne, Westmoreland, Wyoming and York	$461	$587	$724	$859	$976	$121
Armstrong, Bedford, Cambria, Clarion, Clearfield, Fayette, Forest, Fulton, Greene, Huntingdon, Jefferson, Juniata, Northumberland, Schuylkill and Somerset	$406	$532	$662	$791	$894	$121
Beaver, Cameron, Carbon, Clinton, Elk, Franklin, Indiana, Lawrence, McKean, Mercer, Mifflin, Perry, Potter, Snyder, Tioga, Venango and Washington	$444	$573	$698	$829	$943	$121
Bucks, Chester, Lancaster, Montgomery and Pike	$481	$614	$749	$885	$1,001	$121

[50 Pa.B. 6361][Saturday, November 14, 2020]

[Continued from previous Web Page]

APPENDIX B

Co-Payment Chart

Family Co-Payment Scale Effective May 4, 2020

(Based on the 2020 Federal Poverty Income Guidelines)

APPENDIX C

STEPPARENT DEDUCTION CHART

[Pa.B. Doc. No. 20-1570. Filed for public inspection November 13, 2020, 9:00 a.m.]

[50 Pa.B. 6361]
[Saturday, November 14, 2020]