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APPENDIX P TEFRA Premium Schedule How to determine TEFRA Premium Range Step 1 Look at the chart below. If the family has income after allowable deductions at or below the amount listed for the household size, a premium will not be assessed. If the household has income that is greater than the amount listed below for the household size, continue to Step 2. Family Size 150% FPL 1 $ 23,940.00 2 $ 32,460.00 3 $ 40,980.00 4 $ 49,500.00 5 $ 58,020.00 6 $ 66,540.00 7 $ 75,060.00 8 $ 83,580.00 For each additional member add: $ 8,520.00 Step 2 Find the income here to determine the TEFRA Premium Range Annual Income Monthly Premiums From To Percent % From To $0 $25,000 0.0% $0 $0 $25,001 $50,000 1.00% $20 $41 $50,001 $75,000 1.25% $52 $78 $75,001 $100,000 1.50% $93 $125 $100,001 $125,000 1.75% $145 $182 $125,001 $150,000 2.00% $208 $250 $150,001 $175,000 2.25% $281 $328 $175,001 $200,000 2.50% $364 $416 $200,001 Unlimited 2.75% $458 $458 Revised 04/26