Pennsylvania Code › Title 55 - HUMAN SERVICES › Part V - Children, Youth and Families Manual › Subpart B - Eligibility for Services › Chapter 3042 - SUBSIDIZED CHILD CARE ELIGIBILITY › OVERPAYMENT AND DISQUALIFICATION › Appendix B - Copayment Chart

Current through Register Vol. 54, No. 28, July 13, 2024
Family Copayment Scale Effective January 17,
						2022
(Based on the 2022 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:
$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 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:
$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 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:
$9,428
$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 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:
$9,472
$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 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:
$11,872
$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 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:
$9,515
$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 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:
$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