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Lower End Higher End Lower End Higher End Lower End Higher End Lower End Higher End Lower End Higher End 1 $3,588.00 $3,652.00 $202.15 $3,653.00 $3,717.00 $214.38 $3,718.00 $3,783.00 $227.08 $3,784.00 $3,848.00 $239.77 $3,849.00 $3,913.00 $243.92 2 $4,848.00 $4,935.00 $273.23 $4,936.00 $5,024.00 $289.85 $5,025.00 $5,112.00 $306.69 $5,113.00 $5,200.00 $324.00 $5,201.00 $5,288.00 $329.54 3 $6,109.00 $6,219.00 $344.54 $6,220.00 $6,330.00 $365.31 $6,331.00 $6,441.00 $386.54 $6,442.00 $6,552.00 $408.23 $6,553.00 $6,663.00 $415.15 4 $7,369.00 $7,502.00 $415.38 $7,503.00 $7,636.00 $440.54 $7,637.00 $7,770.00 $466.15 $7,771.00 $7,904.00 $492.46 $7,905.00 $8,038.00 $500.77 5 $8,630.00 $8,785.00 $486.46 $8,786.00 $8,942.00 $516.00 $8,943.00 $9,099.00 $546.00 $9,100.00 $9,256.00 $576.69 $9,257.00 $9,413.00 $586.62 6 $9,890.00 $10,069.00 $557.77 $10,070.00 $10,249.00 $591.23 $10,250.00 $10,428.00 $625.62 $10,429.00 $10,608.00 $660.92 $10,609.00 $10,788.00 $672.23 7 $11,150.00 $11,352.00 $628.62 $11,353.00 $11,555.00 $666.69 $11,556.00 $11,758.00 $705.46 $11,759.00 $11,960.00 $745.15 $11,961.00 $12,163.00 $757.85 8 $12,411.00 $12,635.00 $699.69 $12,636.00 $12,861.00 $741.92 $12,862.00 $13,087.00 $785.31 $13,088.00 $13,312.00 $829.38 $13,313.00 $13,538.00 $843.46 9 $13,671.00 $13,919.00 $771.00 $13,920.00 $14,167.00 $817.38 $14,168.00 $14,416.00 $864.92 $14,417.00 $14,664.00 $913.62 $14,665.00 $14,913.00 $929.31 10 $14,932.00 $15,202.00 $841.85 $15,203.00 $15,474.00 $892.85 $15,475.00 $15,745.00 $944.77 $15,746.00 $16,017.00 $998.08 $16,018.00 $16,288.00 $1,014.92 11 $16,192.00 $16,485.00 $912.92 $16,486.00 $16,780.00 $968.08 $16,781.00 $17,074.00 $1,024.38 $17,075.00 $17,369.00 $1,082.31 $17,370.00 $17,663.00 $1,100.54 12 $17,453.00 $17,769.00 $984.23 $17,770.00 $18,086.00 $1,043.54 $18,087.00 $18,403.00 $1,104.23 $18,404.00 $18,721.00 $1,166.54 $18,722.00 $19,038.00 $1,186.15 13 $18,713.00 $19,052.00 $1,055.08 $19,053.00 $19,392.00 $1,118.77 $19,393.00 $19,733.00 $1,184.08 $19,734.00 $20,073.00 $1,250.77 $20,074.00 $20,413.00 $1,272.00 14 $19,973.00 $20,335.00 $1,126.15 $20,336.00 $20,699.00 $1,194.23 $20,700.00 $21,062.00 $1,263.69 $21,063.00 $21,425.00 $1,335.00 $21,426.00 $21,788.00 $1,357.62 15 $21,234.00 $21,619.00 $1,197.46 $21,620.00 $22,005.00 $1,269.46 $22,006.00 $22,391.00 $1,343.54 $22,392.00 $22,777.00 $1,419.23 $22,778.00 $23,163.00 $1,443.23 Weekly Copayment 290% Monthly FPL Family Size Weekly Copayment 280% Monthly FPL 300% Monthly FPL 285% Monthly FPL 295% Monthly FPL Weekly Copayment Weekly Copayment Weekly Copayment