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APPENDIX A-5 Revised 03-01-2026 MONTHLY COUNTABLE PREMIUM MONTHLY COUNTABLE PREMIUM EARNINGS - INDIVIDUAL PER MONTH EARNINGS - COUPLE PER MONTH SLIDING SCALE FOR WORKING DISABLED PREMIUMS* ELIGIBILITY POLICY AND PROCEDURES MANUAL $2680-$2699.99 $134 $3400-$3419.99 $170 $2700-$2719.99 $135 $3420-$3439.99 $171 $2720-$2739.99 $136 $3440-$3459.99 $172 $2740-$2759.99 $137 $3460-$3479.99 $173 $2760-$2779.99 $138 $3480-$3499.99 $174 $2780-$2799.99 $139 $3500-$3519.99 $175 $2800-$2819.99 $140 $3520-$3539.99 $176 $2820-$2839.99 $141 $3540-$3559.99 $177 $2840-$2859.99 $142 $3560-$3579.99 $178 $2860-$2879.99 $143 $3580-$3599.99 $179 $2880-$2899.99 $144 $3600-$3619.99 $180 $2900-$2919.99 $145 $3620-$3639.99 $181 $2920-$2939.99 $146 $3640-$3659.99 $182 $2940-$2959.99 $147 $3660-$3679.99 $183 $2960-$2979.99 $148 $3680-$3699.99 $184 $2980-$2999.99 $149 $3700-$3719.99 $185 $3000-$3019.99 $150 $3720-$3739.99 $186 $3020-$3039.99 $151 $3740-$3759.99 $187 $3040-$3059.99 $152 $3760-$3779.99 $188 $3060-$3079.00 $153 $3780-$3799.99 $189 $3080-$3099.99 $154 $3800-$3819.99 $190 $3100-$3119.99 $155 $3820-$3839.99 $191 $3120-$3139.99 $156 $3840-$3859.99 $192 $3140-$3159.99 $157 $3860-$3879.99 $193 $3160-$3179.99 $158 $3880-$3899.99 $194 $3180-$3199.99 $159 $3900-$3919.99 $195 $3200-$3219.99 $160 $3920-$3939.99 $196 $3220-$3239.99 $161 $3940-$3959.99 $197 $3240-$3259.99 $162 $3960-$3979.99 $198 $3260-$3279.99 $163 $3980-$3999.99 $199 $3280-$3299.99 $164 $4000-$4019.99 $200 $3300-$3319.99 $165 $4020-$4039.99 $201 $3320-$3325 $166 $4040-$4059.99 $202 $4060-$4079.99 $203 $4080-$4099.99 $204 $4100-$4119.99 $205 $4120-$4139.99 $206 $4140-$4159.99 $207