Co-Pay Chart

Co-Pay Chart

Family Fee Scale
(Family Co-Pay Per Day)
Income
Range
Monthly
Family 2 Family
CoPay
with
1 child
Family Size 3
Family CoPay
Family Size 4
Family CoPay
Family Size 5 +
Family CoPay
With 1
Child
With 2
or more
With 1
Child
With 2
or more
With 1
Child
With 2
or more
0
899
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
900
999
$2.50
$2.50
$3.00
$2.50
$2.75
$2.25
$2.75
1,000
1,099
$3.25
$3.25
$3.75
$2.75
$3.25
$2.50
$3.00
1100
1199
$4.00
$4.00
$4.50
$3.25
$3.75
$2.75
$3.25
1200
1299
$4.50
$4.50
$5.00
$4.00
$4.50
$3.00
$3.50
1300
1399
$5.00
$5.00
$5.50
$5.00
$5.50
$3.50
$4.25
1400
1499
$6.50
$5.50
$6.25
$5.50
$6.25
$4.25
$4.75
1500
1599
$7.50
$6.00
$6.75
$6.00
$6.75
$5.00
$5.75
1600
1699
$8.50
$6.50
$7.50
$6.50
$7.50
$6.00
$6.75
1700
1799
$9.50
$7.00
$8.00
$7.00
$8.00
$6.75
$7.50
1800
1899
$10.00
$8.50
$9.50
$7.50
$8.50
$7.50
$8.50
1900
1999
$10.50
$9.50
$10.50
$8.00
$9.00
$8.00
$9.00
2000
2099
$11.00
$10.50
$11.50
$8.50
$9.50
$8.50
$9.50
2100
2199
$12.00
$10.50
$11.50
$9.00
$10.00
$9.00
$10.00
2200
2299
$12.00
$11.50
$12.50
$10.50
$11.50
$9.50
$10.50
2300
2399

$12.50
$13.50
$11.25
$12.25
$9.75
$10.75
2400
2499

$12.50
$13.50
$12.25
$13.25
$10.25
$11.25
2500
2599

$13.50
$14.50
$12.25
$13.25
$10.75
$11.75
2600
2699

$13.50
$14.50
$13.25
$14.50
$12.25
$13.25
2700
2799



$13.25
$14.50
$13.25
$14.25
2800
2899



$14.25
$15.50
$14.25
$15.75
2900
2999



$14.25
$15.50
$16.25
$17.25
3000
3099



$15.25
$16.50
$18.25
$19.25
3100
3199



$15.25
$16.50
$20.25
$21.25
3200
3299





$20.25
$21.25
3300
3399





$22.25
$23.25
3400
3499





$22.25
$23.25
3500
3599





$24.25
$25.25
3600
3699





$24.25
$25.25

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