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52.1 Reserved This page last updated in Release Number: 17-01 Release Date: 04/11/2017 Effective Date: 04/11/2017 53.1 Copay Tables 53.1.1 Five Percent Copay Limit Tiers 2026 Per-Member Copay Limits Status Assistance Group Income Tier as Percentage of the Federal Poverty Level 0- 50% >50- 100% >100- 150% >150- 200% >200- 250% >250- 300% >300- 350% >350- 400% >400- 450% >450- 500% >500% Individual $0 $26 $53 $79 $106 $132 $159 $186 $212 $239 $265 Prorated (split between counted spouses) $0 $13 $26.50 $39.50 $53 $66 $79.50 $93 $106 $119.50 $132.50 53.1.2 Fifty Percent Federal Poverty Level Limits If the assistance group income is less than the applicable amount listed below, no copays are charged. Assistance Group Size Monthly Income 1 $665 2 $901 3 $1,138 4 $1,375 5 $1,611 6 $1,848 This page last updated in Release Number: 26-01 Release Date: 02/13/2026 Effective Date: 02/01/2026