APPENDIX B

Copayment Chart

Family Copayment Scale Effective January 17, 2022

   (Based on the 2022 Federal Poverty Income Guidelines)

   

Weekly	Family Size:	1	Weekly	Family Size:	2	Weekly	Family Size:	3
Co-pay	Annual Income		Co-pay	Annual Income		Co-pay	Annual Income
$5	Less than:	$7,567	$5	Less than:	$8,187	$5	Less than:	$7,741
$6	$7,567.01	$8,324	$6	$8,187.41	$9,211	$6	$7,741.01	$9,031
$7	$8,323.71	$9,080	$7	$9,210.84	$10,234	$7	$9,031.01	$10,321
$8	$9,080.41	$9,837	$8	$10,234.26	$11,258	$8	$10,321.01	$11,611
$9	$9,837.11	$10,594	$9	$11,257.69	$12,281	$9	$11,611.01	$12,902
$9	$10,593.81	$11,351	$10	$12,281.11	$13,305	$10	$12,902.01	$14,192
$10	$11,350.51	$12,107	$12	$13,304.54	$14,328	$12	$14,192.01	$15,482
$11	$12,107.21	$12,864	$13	$14,327.96	$15,351	$13	$15,482.01	$16,772
$12	$12,863.91	$13,621	$14	$15,351.39	$16,375	$15	$16,772.01	$18,062
$13	$13,620.61	$14,377	$15	$16,374.81	$17,398	$16	$18,062.01	$19,352
$14	$14,377.31	$15,134	$17	$17,398.24	$18,422	$18	$19,352.01	$20,642
$15	$15,134.01	$15,891	$18	$18,421.66	$19,445	$19	$20,642.01	$21,933
$16	$15,890.71	$16,647	$19	$19,445.09	$20,469	$21	$21,933.01	$23,223
$17	$16,647.41	$17,404	$21	$20,468.51	$21,492	$23	$23,223.01	$24,513
$19	$17,404.11	$18,161	$22	$21,491.94	$22,515	$24	$24,513.01	$25,803
$20	$18,160.81	$18,918	$24	$22,515.36	$23,539	$26	$25,803.01	$27,093
$21	$18,917.51	$19,674	$25	$23,538.79	$24,562	$28	$27,093.01	$28,383
$22	$19,674.21	$20,431	$27	$24,562.21	$25,586	$30	$28,383.01	$29,673
$23	$20,430.91	$21,188	$28	$25,585.64	$26,609	$32	$29,673.01	$30,964
$24	$21,187.61	$21,944	$30	$26,609.06	$27,632	$34	$30,964.01	$32,254
$26	$21,944.31	$22,701	$31	$27,632.49	$28,656	$36	$32,254.01	$33,544
$27	$22,701.01	$23,458	$33	$28,655.91	$29,679	$38	$33,544.01	$34,834
$28	$23,457.71	$24,214	$35	$29,679.34	$30,703	$40	$34,834.01	$36,124
$30	$24,214.41	$24,971	$36	$30,702.76	$31,726	$42	$36,124.01	$37,414
$31	$24,971.11	$25,728	$38	$31,726.19	$32,750	$44	$37,414.01	$38,705
$32	$25,727.81	$26,485	$40	$32,749.61	$33,773	$46	$38,705.01	$39,995
$34	$26,484.51	$27,241	$42	$33,773.04	$34,796	$48	$39,995.01	$41,285
$35	$27,241.21	$27,998	$44	$34,796.46	$35,820	$51	$41,285.01	$42,575
$37	$27,997.91	$28,755	$46	$35,819.89	$36,843	$53	$42,575.01	$43,865
$38	$28,754.61	$29,511	$48	$36,843.31	$37,867	$55	$43,865.01	$45,155
$40	$29,511.31	$30,268	$50	$37,866.74	$38,890	$58	$45,155.01	$46,445
	200% FPIG	$25,760	$52	$38,890.16	$39,914	$60	$46,445.01	$47,736
			$54	$39,913.59	$40,937	$63	$47,736.01	$49,026
				200% FPIG	$34,840	$65	$49,026.01	$50,316
						$68	$50,316.01	$51,606
							200% FPIG	$43,920

   

Weekly	Family Size:	4	Weekly	Family Size:	5	Weekly	Family Size:	6
Co-pay	Annual Income		Co-pay	Annual Income		Co-pay	Annual Income
$5	Less than:	$9,341	$5	Less than:	$9,118	$5	Less than:	$8,361
$7	$9,341.01	$10,898	$6	$9,118.01	$10,942	$6	$8,361.01	$10,452
$8	$10,898.01	$12,455	$8	$10,942.01	$12,765	$7	$10,452.01	$12,542
$9	$12,455.01	$14,012	$9	$12,765.01	$14,589	$9	$12,542.01	$14,632
$11	$14,012.01	$15,569	$11	$14,589.01	$16,412	$11	$14,632.01	$16,723
$13	$15,569.01	$17,126	$13	$16,412.01	$18,236	$13	$16,723.01	$18,813
$14	$17,126.01	$18,683	$15	$18,236.01	$20,060	$15	$18,813.01	$20,903
$16	$18,683.01	$20,239	$17	$20,060.01	$21,883	$17	$20,903.01	$22,994
$18	$20,239.01	$21,796	$19	$21,883.01	$23,707	$19	$22,994.01	$25,084
$19	$21,796.01	$23,353	$21	$23,707.01	$25,530	$21	$25,084.01	$27,174
$21	$23,353.01	$24,910	$23	$25,530.01	$27,354	$24	$27,174.01	$29,265
$23	$24,910.01	$26,467	$25	$27,354.01	$29,178	$26	$29,265.01	$31,355
$25	$26,467.01	$28,024	$27	$29,178.01	$31,001	$29	$31,355.01	$33,445
$27	$28,024.01	$29,581	$30	$31,001.01	$32,825	$31	$33,445.01	$35,536
$29	$29,581.01	$31,138	$32	$32,825.01	$34,648	$34	$35,536.01	$37,626
$32	$31,138.01	$32,694	$35	$34,648.01	$36,472	$37	$37,626.01	$39,716
$34	$32,694.01	$34,251	$37	$36,472.01	$38,296	$40	$39,716.01	$41,807
$36	$34,251.01	$35,808	$40	$38,296.01	$40,119	$42	$41,807.01	$43,897
$38	$35,808.01	$37,365	$42	$40,119.01	$41,943	$45	$43,897.01	$45,987
$41	$37,365.01	$38,922	$45	$41,943.01	$43,766	$48	$45,987.01	$48,077
$43	$38,922.01	$40,479	$47	$43,766.01	$45,590	$51	$48,077.01	$50,168
$45	$40,479.01	$42,036	$50	$45,590.01	$47,414	$54	$50,168.01	$52,258
$48	$42,036.01	$43,593	$53	$47,414.01	$49,237	$58	$52,258.01	$54,348
$50	$43,593.01	$45,149	$56	$49,237.01	$51,061	$61	$54,348.01	$56,439
$53	$45,149.01	$46,706	$59	$51,061.01	$52,884	$64	$56,439.01	$58,529
$56	$46,706.01	$48,263	$62	$52,884.01	$54,708	$68	$58,529.01	$60,619
$58	$48,263.01	$49,820	$65	$54,708.01	$56,532	$71	$60,619.01	$62,710
$61	$49,820.01	$51,377	$68	$56,532.01	$58,355	$75	$62,710.01	$64,800
$64	$51,377.01	$52,934	$71	$58,355.01	$60,179	$78	$64,800.01	$66,890
$67	$52,934.01	$54,491	$75	$60,179.01	$62,002	$82	$66,890.01	$68,981
$70	$54,491.01	$56,048	$78	$62,002.01	$63,826	$86	$68,981.01	$71,071
$73	$56,048.01	$57,604	$81	$63,826.01	$65,650	$89	$71,071.01	$73,161
$76	$57,604.01	$59,161	$85	$65,650.01	$67,473	$93	$73,161.01	$75,252
$79	$59,161.01	$60,718	$88	$67,473.01	$69,297	$97	$75,252.01	$77,342
$82	$60,718.01	$62,275	$92	$69,297.01	$71,120	$101	$77,342.01	$79,432
	200% FPIG	$53,000	$96	$71,120.01	$72,944	$106	$79,432.01	$81,523
				200% FPIG	$62,080	$110	$81,523.01	$83,613
							200% FPIG	$71,160

Weekly	Family Size:	7	Weekly	Family Size:	8	Weekly	Family Size:	9
Co-pay	Annual Income		Co-pay	Annual Income		Co-pay	Annual Income
$5	Less than:	$9,428	$5	Less than:	$10,495	$5	Less than:	$8,672
$6	$9,428.01	$11,785	$7	$10,495.01	$13,119	$6	$8,672.01	$11,562
$8	$11,785.01	$14,142	$9	$13,119.01	$15,743	$8	$11,562.01	$14,453
$10	$14,142.01	$16,499	$11	$15,743.01	$18,366	$10	$14,453.01	$17,343
$12	$16,499.01	$18,856	$14	$18,366.01	$20,990	$12	$17,343.01	$20,234
$14	$18,856.01	$21,213	$16	$20,990.01	$23,614	$15	$20,234.01	$23,124
$17	$21,213.01	$23,571	$18	$23,614.01	$26,238	$18	$23,124.01	$26,015
$19	$23,571.01	$25,928	$21	$26,238.01	$28,862	$20	$26,015.01	$28,905
$21	$25,928.01	$28,285	$24	$28,862.01	$31,485	$23	$28,905.01	$31,796
$24	$28,285.01	$30,642	$27	$31,485.01	$34,109	$26	$31,796.01	$34,686
$27	$30,642.01	$32,999	$30	$34,109.01	$36,733	$29	$34,686.01	$37,577
$29	$32,999.01	$35,356	$33	$36,733.01	$39,357	$33	$37,577.01	$40,467
$32	$35,356.01	$37,713	$36	$39,357.01	$41,980	$36	$40,467.01	$43,358
$35	$37,713.01	$40,070	$39	$41,980.01	$44,604	$40	$43,358.01	$46,248
$39	$40,070.01	$42,427	$43	$44,604.01	$47,228	$43	$46,248.01	$49,139
$42	$42,427.01	$44,784	$46	$47,228.01	$49,852	$47	$49,139.01	$52,029
$45	$44,784.01	$47,141	$50	$49,852.01	$52,476	$51	$52,029.01	$54,920
$48	$47,141.01	$49,498	$53	$52,476.01	$55,099	$55	$54,920.01	$57,810
$51	$49,498.01	$51,855	$57	$55,099.01	$57,723	$59	$57,810.01	$60,701
$54	$51,855.01	$54,212	$61	$57,723.01	$60,347	$63	$60,701.01	$63,591
$58	$54,212.01	$56,569	$64	$60,347.01	$62,971	$67	$63,591.01	$66,482
$61	$56,569.01	$58,926	$68	$62,971.01	$65,594	$71	$66,482.01	$69,372
$65	$58,926.01	$61,283	$72	$65,594.01	$68,218	$75	$69,372.01	$72,263
$69	$61,283.01	$63,640	$76	$68,218.01	$70,842	$80	$72,263.01	$75,153
$72	$63,640.01	$65,997	$81	$70,842.01	$73,466	$84	$75,153.01	$78,044
$76	$65,997.01	$68,354	$85	$73,466.01	$76,089	$89	$78,044.01	$80,934
$80	$68,354.01	$70,712	$89	$76,089.01	$78,713	$93	$80,934.01	$83,825
$84	$70,712.01	$73,069	$94	$78,713.01	$81,337	$98	$83,825.01	$86,715
$88	$73,069.01	$75,426	$98	$81,337.01	$83,961	$103	$86,715.01	$89,606
$92	$75,426.01	$77,783	$103	$83,961.01	$86,585	$108	$89,606.01	$92,496
$97	$77,783.01	$80,140	$107	$86,585.01	$89,208	$113	$92,496.01	$95,387
$101	$80,140.01	$82,497	$112	$89,208.01	$91,832	$118	$95,387.01	$98,277
$105	$82,497.01	$84,854	$117	$91,832.01	$94,456	$124	$98,277.01	$101,168
$110	$84,854.01	$87,211	$122	$94,456.01	$97,080	$129	$101,168.01	$104,058
$114	$87,211.01	$89,568	$127	$97,080.01	$99,703	$135	$104,058.01	$106,949
$119	$89,568.01	$91,925	$132	$99,703.01	$102,327	$140	$106,949.01	$109,839
$124	$91,925.01	$94,282	$138	$102,327.01	$104,951	$146	$109,839.01	$112,730
	200% FPIG	$80,240		200% FPIG	$89,320	$152	$112,730.01	$115,620
							200% FPIG	$98,400

Weekly	Family Size:	10	Weekly	Family Size:	11	Weekly	Family Size:	12
Co-pay	Annual Income		Co-pay	Annual Income		Co-pay	Annual Income
$5	Less than:	$9,472	$5	Less than:	$10,272	$5	Less than:	$11,072
$6	$9,472.01	$12,629	$7	$10,272.01	$13,696	$7	$11,072.01	$14,763
$8	$12,629.01	$15,786	$9	$13,696.01	$17,120	$10	$14,763.01	$18,453
$11	$15,786.01	$18,943	$12	$17,120.01	$20,544	$13	$18,453.01	$22,144
$14	$18,943.01	$22,101	$15	$20,544.01	$23,968	$16	$22,144.01	$25,835
$16	$22,101.01	$25,258	$18	$23,968.01	$27,392	$19	$25,835.01	$29,525
$19	$25,258.01	$28,415	$21	$27,392.01	$30,816	$22	$29,525.01	$33,216
$22	$28,415.01	$31,572	$24	$30,816.01	$34,240	$26	$33,216.01	$36,907
$25	$31,572.01	$34,729	$28	$34,240.01	$37,663	$30	$36,907.01	$40,597
$29	$34,729.01	$37,887	$31	$37,663.01	$41,087	$34	$40,597.01	$44,288
$32	$37,887.01	$41,044	$35	$41,087.01	$44,511	$38	$44,288.01	$47,979
$36	$41,044.01	$44,201	$39	$44,511.01	$47,935	$42	$47,979.01	$51,669
$40	$44,201.01	$47,358	$43	$47,935.01	$51,359	$46	$51,669.01	$55,360
$43	$47,358.01	$50,516	$47	$51,359.01	$54,783	$51	$55,360.01	$59,051
$47	$50,516.01	$53,673	$51	$54,783.01	$58,207	$55	$59,051.01	$62,741
$52	$53,673.01	$56,830	$56	$58,207.01	$61,631	$60	$62,741.01	$66,432
$56	$56,830.01	$59,987	$60	$61,631.01	$65,055	$65	$66,432.01	$70,123
$60	$59,987.01	$63,145	$65	$65,055.01	$68,479	$70	$70,123.01	$73,814
$64	$63,145.01	$66,302	$69	$68,479.01	$71,903	$75	$73,814.01	$77,504
$68	$66,302.01	$69,459	$74	$71,903.01	$75,327	$80	$77,504.01	$81,195
$73	$69,459.01	$72,616	$79	$75,327.01	$78,751	$85	$81,195.01	$84,886
$77	$72,616.01	$75,773	$84	$78,751.01	$82,175	$91	$84,886.01	$88,576
$82	$75,773.01	$78,931	$89	$82,175.01	$85,599	$96	$88,576.01	$92,267
$87	$78,931.01	$82,088	$94	$85,599.01	$89,023	$102	$92,267.01	$95,958
$92	$82,088.01	$85,245	$100	$89,023.01	$92,447	$107	$95,958.01	$99,648
$97	$85,245.01	$88,402	$105	$92,447.01	$95,871	$113	$99,648.01	$103,339
$102	$88,402.01	$91,560	$111	$95,871.01	$99,295	$119	$103,339.01	$107,030
$107	$91,560.01	$94,717	$116	$99,295.01	$102,719	$125	$107,030.01	$110,720
$113	$94,717.01	$97,874	$122	$102,719.01	$106,142	$132	$110,720.01	$114,411
$118	$97,874.01	$101,031	$128	$106,142.01	$109,566	$138	$114,411.01	$118,102
$124	$101,031.01	$104,188	$134	$109,566.01	$112,990	$145	$118,102.01	$121,792
$129	$104,188.01	$107,346	$140	$112,990.01	$116,414	$151	$121,792.01	$125,483
$135	$107,346.01	$110,503	$147	$116,414.01	$119,838	$158	$125,483.01	$129,174
$141	$110,503.01	$113,660	$153	$119,838.01	$123,262	$165	$129,174.01	$132,864
$147	$113,660.01	$116,817	$159	$123,262.01	$126,686	$172	$132,864.01	$136,555
$153	$116,817.01	$119,975	$166	$126,686.01	$130,110	$179	$136,555.01	$140,246
$159	$119,975.01	$123,132	$173	$130,110.01	$133,534	$186	$140,246.01	$143,936
$166	$123,132.01	$126,289	$180	$133,534.01	$136,958	$194	$143,936.01	$147,627
	200% FPIG	$107,480		200% FPIG	$116,560		200% FPIG	$125,640

Weekly	Family Size:	13	Weekly	Family Size:	14	Weekly	Family Size:	15
Co-pay	Annual Income		Co-pay	Annual Income		Co-pay	Annual Income
$5	Less than:	$11,872	$5	Less than:	$12,672	$5	Less than:	$8,982
$8	$11,872.01	$15,830	$8	$12,672.01	$16,897	$6	$8,982.01	$13,473
$11	$15,830.01	$19,787	$11	$16,897.01	$21,121	$9	$13,473.01	$17,963
$14	$19,787.01	$23,744	$15	$21,121.01	$25,345	$12	$17,963.01	$22,454
$17	$23,744.01	$27,702	$18	$25,345.01	$29,569	$15	$22,454.01	$26,945
$20	$27,702.01	$31,659	$22	$29,569.01	$33,793	$19	$26,945.01	$31,436
$24	$31,659.01	$35,617	$26	$33,793.01	$38,017	$23	$31,436.01	$35,927
$28	$35,617.01	$39,574	$30	$38,017.01	$42,241	$27	$35,927.01	$40,418
$32	$39,574.01	$43,531	$34	$42,241.01	$46,465	$32	$40,418.01	$44,909
$36	$43,531.01	$47,489	$38	$46,465.01	$50,690	$36	$44,909.01	$49,399
$40	$47,489.01	$51,446	$43	$50,690.01	$54,914	$41	$49,399.01	$53,890
$45	$51,446.01	$55,404	$48	$54,914.01	$59,138	$46	$53,890.01	$58,381
$50	$55,404.01	$59,361	$53	$59,138.01	$63,362	$51	$58,381.01	$62,872
$54	$59,361.01	$63,318	$58	$63,362.01	$67,586	$56	$62,872.01	$67,363
$59	$63,318.01	$67,276	$63	$67,586.01	$71,810	$62	$67,363.01	$71,854
$65	$67,276.01	$71,233	$69	$71,810.01	$76,034	$67	$71,854.01	$76,344
$70	$71,233.01	$75,191	$74	$76,034.01	$80,258	$73	$76,344.01	$80,835
$75	$75,191.01	$79,148	$80	$80,258.01	$84,483	$79	$80,835.01	$85,326
$80	$79,148.01	$83,105	$86	$84,483.01	$88,707	$85	$85,326.01	$89,817
$86	$83,105.01	$87,063	$91	$88,707.01	$92,931	$91	$89,817.01	$94,308
$91	$87,063.01	$91,020	$97	$92,931.01	$97,155	$97	$94,308.01	$98,799
$97	$91,020.01	$94,978	$104	$97,155.01	$101,379	$104	$98,799.01	$103,290
$103	$94,978.01	$98,935	$110	$101,379.01	$105,603	$110	$103,290.01	$107,780
$109	$98,935.01	$102,892	$116	$105,603.01	$109,827	$117	$107,780.01	$112,271
$115	$102,892.01	$106,850	$123	$109,827.01	$114,051	$124	$112,271.01	$116,762
$121	$106,850.01	$110,807	$130	$114,051.01	$118,276	$131	$116,762.01	$121,253
$128	$110,807.01	$114,765	$136	$118,276.01	$122,500	$138	$121,253.01	$125,744
$134	$114,765.01	$118,722	$143	$122,500.01	$126,724	$145	$125,744.01	$130,235
$141	$118,722.01	$122,679	$151	$126,724.01	$130,948	$153	$130,235.01	$134,726
$148	$122,679.01	$126,637	$158	$130,948.01	$135,172	$160	$134,726.01	$139,216
$155	$126,637.01	$130,594	$165	$135,172.01	$139,396	$168	$139,216.01	$143,707
$162	$130,594.01	$134,552	$173	$139,396.01	$143,620	$176	$143,707.01	$148,198
$169	$134,552.01	$138,509	$181	$143,620.01	$147,844	$184	$148,198.01	$152,689
$177	$138,509.01	$142,466	$189	$147,844.01	$152,069	$192	$152,689.01	$157,180
$184	$142,466.01	$146,424	$197	$152,069.01	$156,293	$201	$157,180.01	$161,671
$192	$146,424.01	$150,381	$205	$156,293.01	$160,517	$209	$161,671.01	$166,161
$200	$150,381.01	$154,339	$213	$160,517.01	$164,741	$218	$166,161.01	$170,652
$208	$154,339.01	$158,296	$222	$164,741.01	$168,965	$227	$170,652.01	$175,143
	200% FPIG	$134,720		200% FPIG	$143,800	$236	$175,143.01	$179,634
							200% FPIG	$152,880

Weekly	Family Size:	16	Weekly	Family Size:	17	Weekly	Family Size:	18
Co-pay	Annual Income		Co-pay	Annual Income		Co-pay	Annual Income
$5	Less than:	$9,515	$5	Less than:	$10,049	$5	Less than:	$10,582
$6	$9,515.01	$14,273	$6	$10,049.01	$15,073	$7	$10,582.01	$15,873
$9	$14,273.01	$19,030	$10	$15,073.01	$20,097	$10	$15,873.01	$21,164
$13	$19,030.01	$23,788	$13	$20,097.01	$25,122	$14	$21,164.01	$26,455
$16	$23,788.01	$28,545	$17	$25,122.01	$30,146	$18	$26,455.01	$31,746
$20	$28,545.01	$33,303	$21	$30,146.01	$35,170	$23	$31,746.01	$37,037
$24	$33,303.01	$38,061	$26	$35,170.01	$40,194	$27	$37,037.01	$42,328
$29	$38,061.01	$42,818	$30	$40,194.01	$45,219	$32	$42,328.01	$47,619
$33	$42,818.01	$47,576	$35	$45,219.01	$50,243	$37	$47,619.01	$52,910
$38	$47,576.01	$52,333	$40	$50,243.01	$55,267	$42	$52,910.01	$58,201
$43	$52,333.01	$57,091	$46	$55,267.01	$60,292	$48	$58,201.01	$63,492
$48	$57,091.01	$61,848	$51	$60,292.01	$65,316	$54	$63,492.01	$68,783
$54	$61,848.01	$66,606	$57	$65,316.01	$70,340	$60	$68,783.01	$74,074
$60	$66,606.01	$71,364	$63	$70,340.01	$75,365	$66	$74,074.01	$79,365
$65	$71,364.01	$76,121	$69	$75,365.01	$80,389	$73	$79,365.01	$84,656
$71	$76,121.01	$80,879	$75	$80,389.01	$85,413	$79	$84,656.01	$89,947
$78	$80,879.01	$85,636	$82	$85,413.01	$90,437	$86	$89,947.01	$95,238
$84	$85,636.01	$90,394	$89	$90,437.01	$95,462	$93	$95,238.01	$100,529
$90	$90,394.01	$95,152	$95	$95,462.01	$100,486	$100	$100,529.01	$105,821
$96	$95,152.01	$99,909	$102	$100,486.01	$105,510	$107	$105,821.01	$111,112
$103	$99,909.01	$104,667	$109	$105,510.01	$110,535	$115	$111,112.01	$116,403
$110	$104,667.01	$109,424	$116	$110,535.01	$115,559	$122	$116,403.01	$121,694
$117	$109,424.01	$114,182	$123	$115,559.01	$120,583	$130	$121,694.01	$126,985
$124	$114,182.01	$118,939	$131	$120,583.01	$125,608	$138	$126,985.01	$132,276
$131	$118,939.01	$123,697	$138	$125,608.01	$130,632	$146	$132,276.01	$137,567
$138	$123,697.01	$128,455	$146	$130,632.01	$135,656	$154	$137,567.01	$142,858
$146	$128,455.01	$133,212	$154	$135,656.01	$140,680	$162	$142,858.01	$148,149
$154	$133,212.01	$137,970	$162	$140,680.01	$145,705	$171	$148,149.01	$153,440
$162	$137,970.01	$142,727	$171	$145,705.01	$150,729	$180	$153,440.01	$158,731
$170	$142,727.01	$147,485	$179	$150,729.01	$155,753	$189	$158,731.01	$164,022
$178	$147,485.01	$152,242	$188	$155,753.01	$160,778	$198	$164,022.01	$169,313
$186	$152,242.01	$157,000	$197	$160,778.01	$165,802	$207	$169,313.01	$174,604
$195	$157,000.01	$161,758	$206	$165,802.01	$170,826	$217	$174,604.01	$179,895
$204	$161,758.01	$166,515	$215	$170,826.01	$175,851	$226	$179,895.01	$185,186
$213	$166,515.01	$171,273	$224	$175,851.01	$180,875	$236	$185,186.01	$190,477
$222	$171,273.01	$176,030	$234	$180,875.01	$185,899	$246	$190,477.01	$195,768
$231	$176,030.01	$180,788	$244	$185,899.01	$190,923	$257	$195,768.01	$201,059
$240	$180,788.01	$185,545	$254	$190,923.01	$195,948	$267	$201,059.01	$206,350
$250	$185,545.01	$190,303	$264	$195,948.01	$200,972	$278	$206,350.01	$211,641
	200% FPIG	$161,960		200% FPIG	$171,040		200% FPIG	$180,120

Weekly	Family Size:	19	Weekly	Family Size:	20	Weekly	Family Size:	21
Co-pay	Annual Income		Co-pay	Annual Income		Co-pay	Annual Income
$5	Less than:	$11,116	$5	Less than:	$11,649	$5	Less than:	$12,182
$7	$11,116.01	$16,673	$7	$11,649.01	$17,473	$8	$12,182.01	$18,274
$11	$16,673.01	$22,231	$11	$17,473.01	$23,298	$12	$18,274.01	$24,365
$15	$22,231.01	$27,789	$16	$23,298.01	$29,122	$16	$24,365.01	$30,456
$19	$27,789.01	$33,347	$20	$29,122.01	$34,947	$21	$30,456.01	$36,547
$24	$33,347.01	$38,904	$25	$34,947.01	$40,771	$26	$36,547.01	$42,638
$29	$38,904.01	$44,462	$30	$40,771.01	$46,596	$31	$42,638.01	$48,730
$34	$44,462.01	$50,020	$35	$46,596.01	$52,420	$37	$48,730.01	$54,821
$39	$50,020.01	$55,578	$41	$52,420.01	$58,245	$43	$54,821.01	$60,912
$45	$55,578.01	$61,135	$47	$58,245.01	$64,069	$49	$60,912.01	$67,003
$50	$61,135.01	$66,693	$53	$64,069.01	$69,894	$55	$67,003.01	$73,094
$57	$66,693.01	$72,251	$59	$69,894.01	$75,718	$62	$73,094.01	$79,186
$63	$72,251.01	$77,809	$66	$75,718.01	$81,543	$69	$79,186.01	$85,277
$70	$77,809.01	$83,366	$73	$81,543.01	$87,367	$76	$85,277.01	$91,368
$76	$83,366.01	$88,924	$80	$87,367.01	$93,192	$84	$91,368.01	$97,459
$83	$88,924.01	$94,482	$87	$93,192.01	$99,016	$92	$97,459.01	$103,550
$91	$94,482.01	$100,040	$95	$99,016.01	$104,841	$100	$103,550.01	$109,642
$98	$100,040.01	$105,597	$103	$104,841.01	$110,665	$107	$109,642.01	$115,733
$105	$105,597.01	$111,155	$110	$110,665.01	$116,490	$115	$115,733.01	$121,824
$113	$111,155.01	$116,713	$118	$116,490.01	$122,314	$124	$121,824.01	$127,915
$120	$116,713.01	$122,271	$126	$122,314.01	$128,138	$132	$127,915.01	$134,006
$128	$122,271.01	$127,828	$134	$128,138.01	$133,963	$141	$134,006.01	$140,098
$136	$127,828.01	$133,386	$143	$133,963.01	$139,787	$149	$140,098.01	$146,189
$145	$133,386.01	$138,944	$152	$139,787.01	$145,612	$158	$146,189.01	$152,280
$153	$138,944.01	$144,502	$160	$145,612.01	$151,436	$168	$152,280.01	$158,371
$162	$144,502.01	$150,059	$169	$151,436.01	$157,261	$177	$158,371.01	$164,462
$171	$150,059.01	$155,617	$179	$157,261.01	$163,085	$187	$164,462.01	$170,554
$180	$155,617.01	$161,175	$188	$163,085.01	$168,910	$197	$170,554.01	$176,645
$189	$161,175.01	$166,733	$198	$168,910.01	$174,734	$207	$176,645.01	$182,736
$198	$166,733.01	$172,290	$208	$174,734.01	$180,559	$217	$182,736.01	$188,827
$208	$172,290.01	$177,848	$218	$180,559.01	$186,383	$228	$188,827.01	$194,918
$218	$177,848.01	$183,406	$228	$186,383.01	$192,208	$239	$194,918.01	$201,010
$228	$183,406.01	$188,964	$239	$192,208.01	$198,032	$250	$201,010.01	$207,101
$238	$188,964.01	$194,521	$249	$198,032.01	$203,857	$261	$207,101.01	$213,192
$248	$194,521.01	$200,079	$260	$203,857.01	$209,681	$272	$213,192.01	$219,283
$259	$200,079.01	$205,637	$271	$209,681.01	$215,506	$284	$219,283.01	$225,374
$270	$205,637.01	$211,195	$283	$215,506.01	$221,330	$296	$225,374.01	$231,466
$281	$211,195.01	$216,752	$294	$221,330.01	$227,155	$308	$231,466.01	$237,557
$292	$216,752.01	$222,310	$306	$227,155.01	$232,979	$320	$237,557.01	$243,648
	200% FPIG	$189,200		200% FPIG	$198,280		200% FPIG	$207,360

Cross References

   This appendix cited in 55 Pa. Code §  3042.97 (relating to use of the Federal Poverty Income Guidelines and State Median Income); and 55 Pa. Code §  3042.98 (relating to copayment determination).

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