Appendix B.

Co-Payment Chart
Family Co-Payment Scale Effective May 4, 2015

(Based on the 2015 Federal Poverty Income Guidelines)

Weekly	Family Size:	1	Weekly	Family Size:	2	Weekly	Family Size:	3
Co-pay	Annual Income		Co-pay	Annual Income		Co-pay	Annual Income
$5.00	Less than:	$9,770	$5.00	Less than:	$8,660	$5.00	Less than:	$8,660
$10.00	$9,770.01	$11,770	$10.00	$8,660.01	$13,000	$10.00	$8,660.01	$14,090
$15.00	$11,770.01	$13,770	$16.00	$13,000.01	$13,930	$17.00	$14,090.01	$16,090
$20.00	$13,770.01	$15,770	$21.00	$13,930.01	$15,930	$22.00	$16,090.01	$18,090
$25.00	$15,770.01	$17,770	$25.00	$15,930.01	$17,930	$27.00	$18,090.01	$20,090
$30.00	$17,770.01	$19,770	$29.00	$17,930.01	$19,930	$31.00	$20,090.01	$22,090
$35.00	$19,770.01	$21,770	$33.00	$19,930.01	$21,930	$35.00	$22,090.01	$24,090
$40.00	$21,770.01	$23,770	$38.00	$21,930.01	$23,930	$39.00	$24,090.01	$26,090
$45.00	$23,770.01	$25,770	$43.00	$23,930.01	$25,930	$43.00	$26,090.01	$28,090
$50.00	$25,770.01	$27,660	$48.00	$25,930.01	$27,930	$48.00	$28,090.01	$30,090
			$53.00	$27,930.01	$29,930	$53.00	$30,090.01	$32,090
			$58.00	$29,930.01	$31,930	$58.00	$32,090.01	$34,090
			$64.00	$31,930.01	$33,930	$63.00	$34,090.01	$36,090
			$70.00	$33,930.01	$35,930	$68.00	$36,090.01	$38,090
			$75.00	$35,930.01	$37,436	$73.00	$38,090.01	$40,090
						$79.00	$40,090.01	$42,090
						$85.00	$42,090.01	$44,090
						$91.00	$44,090.01	$46,090
						$97.00	$46,090.01	$47,212
	200% FPIG	$23,540		200% FPIG	$31,860		200% FPIG	$40,180

Weekly	Family Size:	4	Weekly	Family Size:	5	Weekly	Family Size:	6
Co-pay	Annual Income		Co-pay	Annual Income		Co-pay	Annual Income
$5.00	Less than:	$8,660	$5.00	Less than:	$8,660	$5.00	Less than:	$8,660
$10.00	$8,660.01	$15,930	$10.00	$8,660.01	$16,000	$10.00	$8,660.01	$18,180
$19.00	$15,930.01	$18,000	$19.00	$16,000.01	$18,410	$20.00	$18,180.01	$20,200
$24.00	$18,000.01	$20,000	$23.00	$18,410.01	$20,410	$24.00	$20,200.01	$22,200
$28.00	$20,000.01	$22,000	$27.00	$20,410.01	$22,410	$28.00	$22,200.01	$24,200
$33.00	$22,000.01	$24,250	$31.00	$22,410.01	$24,410	$32.00	$24,200.01	$26,200
$37.00	$24,250.01	$26,250	$35.00	$24,410.01	$26,410	$36.00	$26,200.01	$28,200
$41.00	$26,250.01	$28,250	$40.00	$26,410.01	$28,410	$41.00	$28,200.01	$30,200
$45.00	$28,250.01	$30,250	$44.00	$28,410.01	$30,000	$46.00	$30,200.01	$32,570
$49.00	$30,250.01	$32,250	$47.00	$30,000.01	$32,000	$50.00	$32,570.01	$34,570
$53.00	$32,250.01	$34,250	$51.00	$32,000.01	$34,000	$54.00	$34,570.01	$36,570
$58.00	$34,250.01	$36,250	$55.00	$34,000.01	$36,000	$58.00	$36,570.01	$38,570
$63.00	$36,250.01	$38,250	$59.00	$36,000.01	$38,000	$62.00	$38,570.01	$40,570
$68.00	$38,250.01	$40,250	$63.00	$38,000.01	$40,000	$66.00	$40,570.01	$42,570
$73.00	$40,250.01	$42,250	$68.00	$40,000.01	$42,000	$70.00	$42,570.01	$44,570
$78.00	$42,250.01	$44,250	$73.00	$42,000.01	$44,000	$75.00	$44,570.01	$46,570
$83.00	$44,250.01	$46,250	$78.00	$44,000.01	$46,000	$80.00	$46,570.01	$48,570
$89.00	$46,250.01	$48,250	$83.00	$46,000.01	$48,000	$85.00	$48,570.01	$50,570
$95.00	$48,250.01	$50,250	$88.00	$48,000.01	$50,000	$90.00	$50,570.01	$52,570
$101.00	$50,250.01	$52,250	$93.00	$50,000.01	$52,000	$95.00	$52,570.01	$54,570
$107.00	$52,250.01	$54,250	$98.00	$52,000.01	$54,000	$100.00	$54,570.01	$56,570
$113.00	$54,250.01	$56,250	$103.00	$54,000.01	$56,000	$105.00	$56,570.01	$58,570
$118.00	$56,250.01	$56,988	$109.00	$56,000.01	$58,000	$110.00	$58,570.01	$60,570
			$115.00	$58,000.01	$60,000	$115.00	$60,570.01	$62,570
			$121.00	$60,000.01	$62,000	$121.00	$62,570.01	$64,570
			$127.00	$62,000.01	$64,000	$127.00	$64,570.01	$66,570
			$134.00	$64,000.01	$66,000	$133.00	$66,570.01	$68,570
						$139.00	$68,570.01	$70,570
						$145.00	$70,570.01	$72,570
						$151.00	$72,570.01	$74,570
						$156.00	$74,570.01	$76,540
	200% FPIG	$48,500		200% FPIG	$56,820		200% FPIG	$65,140

Weekly	Family Size:	7	Weekly	Family Size:	8	Weekly	Family Size:	9
Co-pay	Annual Income		Co-pay	Annual Income		Co-pay	Annual Income
$5.00	Less than:	$8,660	$5.00	Less than:	$8,660	$5.00	Less than:	$8,660
$10.00	$8,660.01	$17,600	$10.00	$8,660.01	$19,000	$10.00	$8,660.01	$19,850
$21.00	$17,600.01	$20,000	$22.00	$19,000.01	$22,190	$23.00	$19,850.01	$24,050
$24.00	$20,000.01	$22,200	$26.00	$22,190.01	$24,590	$28.00	$24,050.01	$26,050
$27.00	$22,200.01	$24,030	$29.00	$24,590.01	$26,890	$31.00	$26,050.01	$29,050
$30.00	$24,030.01	$26,030	$33.00	$26,890.01	$28,890	$35.00	$29,050.01	$31,050
$34.00	$26,030.01	$28,030	$37.00	$28,890.01	$30,890	$39.00	$31,050.01	$33,050
$38.00	$28,030.01	$30,030	$41.00	$30,890.01	$32,890	$43.00	$33,050.01	$35,050
$42.00	$30,030.01	$32,730	$45.00	$32,890.01	$34,890	$47.00	$35,050.01	$37,050
$48.00	$32,730.01	$34,730	$49.00	$34,890.01	$36,890	$51.00	$37,050.01	$39,050
$53.00	$34,730.01	$36,730	$54.00	$36,890.01	$38,890	$55.00	$39,050.01	$41,050
$57.00	$36,730.01	$38,230	$59.00	$38,890.01	$40,890	$60.00	$41,050.01	$43,050
$60.00	$38,230.01	$40,230	$63.00	$40,890.01	$42,490	$65.00	$43,050.01	$45,050
$64.00	$40,230.01	$42,230	$66.00	$42,490.01	$44,490	$69.00	$45,050.01	$47,050
$68.00	$42,230.01	$44,230	$70.00	$44,490.01	$46,490	$73.00	$47,050.01	$49,050
$72.00	$44,230.01	$46,230	$74.00	$46,490.01	$48,490	$77.00	$49,050.01	$51,050
$76.00	$46,230.01	$48,230	$78.00	$48,490.01	$50,490	$81.00	$51,050.01	$53,050
$80.00	$48,230.01	$50,230	$82.00	$50,490.01	$52,490	$85.00	$53,050.01	$55,050
$85.00	$50,230.01	$52,230	$86.00	$52,490.01	$54,490	$89.00	$55,050.01	$57,050
$90.00	$52,230.01	$54,230	$90.00	$54,490.01	$56,490	$93.00	$57,050.01	$59,050
$95.00	$54,230.01	$56,230	$95.00	$56,490.01	$58,490	$97.00	$59,050.01	$61,050
$100.00	$56,230.01	$58,230	$100.00	$58,490.01	$60,490	$101.00	$61,050.01	$63,050
$105.00	$58,230.01	$60,230	$105.00	$60,490.01	$62,490	$106.00	$63,050.01	$65,050
$110.00	$60,230.01	$62,230	$110.00	$62,490.01	$64,490	$111.00	$65,050.01	$67,050
$115.00	$62,230.01	$64,230	$115.00	$64,490.01	$66,490	$116.00	$67,050.01	$69,050
$120.00	$64,230.01	$66,230	$120.00	$66,490.01	$68,490	$121.00	$69,050.01	$71,050
$125.00	$66,230.01	$68,230	$125.00	$68,490.01	$70,490	$126.00	$71,050.01	$73,050
$130.00	$68,230.01	$70,230	$130.00	$70,490.01	$72,490	$131.00	$73,050.01	$75,050
$136.00	$70,230.01	$72,230	$135.00	$72,490.01	$74,490	$136.00	$75,050.01	$77,050
$142.00	$72,230.01	$74,230	$140.00	$74,490.01	$76,490	$141.00	$77,050.01	$79,050
$148.00	$74,230.01	$76,230	$145.00	$76,490.01	$78,490	$146.00	$79,050.01	$81,050
$154.00	$76,230.01	$78,230	$151.00	$78,490.01	$80,490	$151.00	$81,050.01	$83,050
$160.00	$78,230.01	$80,230	$157.00	$80,490.01	$82,490	$156.00	$83,050.01	$85,050
$166.00	$80,230.01	$82,230	$163.00	$82,490.01	$84,490	$161.00	$85,050.01	$87,050
$172.00	$82,230.01	$86,316	$169.00	$84,490.01	$86,490	$167.00	$87,050.01	$89,050
			$175.00	$86,490.01	$88,490	$173.00	$89,050.01	$91,050
			$181.00	$88,490.01	$90,490	$179.00	$91,050.01	$93,050
			$187.00	$90,490.01	$92,490	$185.00	$93,050.01	$95,050
			$193.00	$92,490.01	$94,490	$191.00	$95,050.01	$97,050
			$198.00	$94,490.01	$96,092	$197.00	$97,050.01	$99,050
						$203.00	$99,050.01	$101,050
						$209.00	$101,050.01	$103,050
						$216.00	$103,050.01	$105,050
	200% FPIG	$73,460		200% FPIG	$81,780		200% FPIG	$90,100

Weekly	Family Size:	10	Weekly	Family Size:	11	Weekly	Family Size:	12
Co-pay	Annual Income		Co-pay	Annual Income		Co-pay	Annual Income
$5.00	Less than:	$8,660	$5.00	Less than:	$8,660	$5.00	Less than:	$8,660
$10.00	$8,660.01	$21,610	$10.00	$8,660.01	$22,470	$10.00	$8,660.01	$23,370
$25.00	$21,610.01	$25,910	$26.00	$22,470.01	$25,000	$27.00	$23,370.01	$31,130
$30.00	$25,910.01	$29,010	$29.00	$25,000.01	$28,370	$36.00	$31,130.01	$34,530
$34.00	$29,010.01	$31,010	$33.00	$28,370.01	$30,370	$41.00	$34,530.01	$36,530
$37.00	$31,010.01	$33,010	$36.00	$30,370.01	$32,370	$45.00	$36,530.01	$38,530
$41.00	$33,010.01	$35,010	$39.00	$32,370.01	$34,370	$49.00	$38,530.01	$40,530
$45.00	$35,010.01	$37,010	$43.00	$34,370.01	$36,370	$53.00	$40,530.01	$42,530
$49.00	$37,010.01	$39,010	$47.00	$36,370.01	$38,370	$57.00	$42,530.01	$44,530
$53.00	$39,010.01	$41,010	$51.00	$38,370.01	$40,370	$61.00	$44,530.01	$46,530
$57.00	$41,010.01	$43,010	$55.00	$40,370.01	$42,370	$65.00	$46,530.01	$48,530
$61.00	$43,010.01	$45,010	$59.00	$42,370.01	$44,370	$69.00	$48,530.01	$50,530
$66.00	$45,010.01	$47,010	$63.00	$44,370.01	$46,370	$73.00	$50,530.01	$52,530
$71.00	$47,010.01	$49,210	$67.00	$46,370.01	$48,370	$78.00	$52,530.01	$54,530
$75.00	$49,210.01	$50,810	$72.00	$48,370.01	$50,370	$83.00	$54,530.01	$57,530
$78.00	$50,810.01	$52,810	$77.00	$50,370.01	$53,370	$88.00	$57,530.01	$59,530
$82.00	$52,810.01	$54,810	$82.00	$53,370.01	$55,370	$92.00	$59,530.01	$61,530
$86.00	$54,810.01	$56,810	$86.00	$55,370.01	$57,370	$96.00	$61,530.01	$63,530
$90.00	$56,810.01	$58,810	$90.00	$57,370.01	$59,370	$100.00	$63,530.01	$65,530
$94.00	$58,810.01	$60,810	$94.00	$59,370.01	$61,370	$104.00	$65,530.01	$67,530
$98.00	$60,810.01	$62,810	$98.00	$61,370.01	$63,370	$108.00	$67,530.01	$69,530
$102.00	$62,810.01	$64,810	$102.00	$63,370.01	$65,370	$112.00	$69,530.01	$71,530
$106.00	$64,810.01	$66,810	$106.00	$65,370.01	$67,370	$116.00	$71,530.01	$73,530
$111.00	$66,810.01	$68,810	$110.00	$67,370.01	$69,370	$120.00	$73,530.01	$75,530
$116.00	$68,810.01	$70,810	$114.00	$69,370.01	$71,370	$124.00	$75,530.01	$77,530
$121.00	$70,810.01	$72,810	$119.00	$71,370.01	$73,370	$128.00	$77,530.01	$79,530
$126.00	$72,810.01	$74,810	$124.00	$73,370.01	$75,370	$133.00	$79,530.01	$81,530
$131.00	$74,810.01	$76,810	$129.00	$75,370.01	$77,370	$138.00	$81,530.01	$83,530
$136.00	$76,810.01	$78,810	$134.00	$77,370.01	$79,370	$143.00	$83,530.01	$85,530
$141.00	$78,810.01	$80,810	$139.00	$79,370.01	$81,370	$148.00	$85,530.01	$87,530
$146.00	$80,810.01	$82,810	$144.00	$81,370.01	$83,370	$153.00	$87,530.01	$89,530
$151.00	$82,810.01	$84,810	$149.00	$83,370.01	$85,370	$158.00	$89,530.01	$91,530
$156.00	$84,810.01	$86,810	$154.00	$85,370.01	$87,370	$163.00	$91,530.01	$93,530
$161.00	$86,810.01	$88,810	$159.00	$87,370.01	$89,370	$168.00	$93,530.01	$95,530
$166.00	$88,810.01	$90,810	$164.00	$89,370.01	$91,370	$173.00	$95,530.01	$97,530
$171.00	$90,810.01	$92,810	$169.00	$91,370.01	$93,370	$178.00	$97,530.01	$99,530
$177.00	$92,810.01	$94,810	$174.00	$93,370.01	$95,370	$183.00	$99,530.01	$101,530
$183.00	$94,810.01	$96,810	$179.00	$95,370.01	$97,370	$188.00	$101,530.01	$103,530
$189.00	$96,810.01	$98,810	$184.00	$97,370.01	$99,370	$193.00	$103,530.01	$105,530
$195.00	$98,810.01	$100,810	$189.00	$99,370.01	$101,370	$198.00	$105,530.01	$107,530
$201.00	$100,810.01	$102,810	$195.00	$101,370.01	$103,370	$203.00	$107,530.01	$109,530
$207.00	$102,810.01	$104,810	$201.00	$103,370.01	$105,370	$209.00	$109,530.01	$111,530
$213.00	$104,810.01	$106,810	$207.00	$105,370.01	$107,370	$215.00	$111,530.01	$113,530
$219.00	$106,810.01	$108,810	$213.00	$107,370.01	$109,370	$221.00	$113,530.01	$115,530
$225.00	$108,810.01	$110,810	$219.00	$109,370.01	$111,370	$227.00	$115,530.01	$117,530
$232.00	$110,810.01	$115,644	$225.00	$111,370.01	$113,370	$233.00	$117,530.01	$119,530
			$231.00	$113,370.01	$115,370	$239.00	$119,530.01	$121,530
			$237.00	$115,370.01	$117,370	$245.00	$121,530.01	$123,530
			$243.00	$117,370.01	$119,370	$251.00	$123,530.01	$125,530
			$249.00	$119,370.01	$121,370	$257.00	$125,530.01	$127,530
			$255.00	$121,370.01	$123,370	$263.00	$127,530.01	$129,530
			$261.00	$123,370.01	$125,370	$269.00	$129,530.01	$131,530
						$275.00	$131,530.01	$133,530
						$280.00	$133,530.01	$135,196
	200% FPIG	$98,420		200% FPIG	$106,740		200% FPIG	$115,060

Weekly	Family Size:	13	Weekly	Family Size:	14	Weekly	Family Size:	15
Co-pay	Annual Income		Co-pay	Annual Income		Co-pay	Annual Income
$5.00	Less than:	$8,660	$5.00	Less than:	$8,660	$5.00	Less than:	$8,660
$10.00	$8,660.01	$25,110	$10.00	$8,660.01	$25,110	$10.00	$8,660.01	$29,410
$29.00	$25,110.01	$31,110	$29.00	$25,110.01	$31,150	$34.00	$29,410.01	$37,110
$36.00	$31,110.01	$34,690	$36.00	$31,150.01	$36,550	$43.00	$37,110.01	$39,110
$41.00	$34,690.01	$36,690	$43.00	$36,550.01	$38,550	$46.00	$39,110.01	$41,110
$44.00	$36,690.01	$38,690	$46.00	$38,550.01	$40,550	$49.00	$41,110.01	$43,110
$47.00	$38,690.01	$40,690	$49.00	$40,550.01	$42,550	$52.00	$43,110.01	$45,110
$51.00	$40,690.01	$42,690	$53.00	$42,550.01	$44,550	$56.00	$45,110.01	$47,110
$55.00	$42,690.01	$44,690	$57.00	$44,550.01	$46,550	$60.00	$47,110.01	$49,110
$59.00	$44,690.01	$46,690	$61.00	$46,550.01	$48,550	$64.00	$49,110.01	$51,110
$63.00	$46,690.01	$48,690	$65.00	$48,550.01	$50,550	$68.00	$51,110.01	$53,110
$67.00	$48,690.01	$50,690	$69.00	$50,550.01	$52,550	$72.00	$53,110.01	$55,110
$71.00	$50,690.01	$52,690	$73.00	$52,550.01	$54,550	$76.00	$55,110.01	$57,110
$75.00	$52,690.01	$54,690	$77.00	$54,550.01	$56,550	$80.00	$57,110.01	$59,110
$79.00	$54,690.01	$56,690	$81.00	$56,550.01	$58,550	$84.00	$59,110.01	$61,110
$84.00	$56,690.01	$58,690	$85.00	$58,550.01	$60,550	$88.00	$61,110.01	$63,110
$89.00	$58,690.01	$61,690	$90.00	$60,550.01	$62,850	$92.00	$63,110.01	$65,110
$94.00	$61,690.01	$63,690	$95.00	$62,850.01	$65,850	$97.00	$65,110.01	$67,110
$98.00	$63,690.01	$65,690	$100.00	$65,850.01	$67,850	$102.00	$67,110.01	$70,010
$102.00	$65,690.01	$67,690	$104.00	$67,850.01	$69,850	$107.00	$70,010.01	$71,510
$106.00	$67,690.01	$69,690	$108.00	$69,850.01	$71,850	$110.00	$71,510.01	$73,510
$110.00	$69,690.01	$71,690	$112.00	$71,850.01	$73,850	$114.00	$73,510.01	$75,510
$114.00	$71,690.01	$73,690	$116.00	$73,850.01	$75,850	$118.00	$75,510.01	$77,510
$118.00	$73,690.01	$75,690	$120.00	$75,850.01	$77,850	$122.00	$77,510.01	$79,510
$122.00	$75,690.01	$77,690	$124.00	$77,850.01	$79,850	$126.00	$79,510.01	$81,510
$126.00	$77,690.01	$79,690	$128.00	$79,850.01	$81,850	$130.00	$81,510.01	$83,510
$130.00	$79,690.01	$81,690	$132.00	$81,850.01	$83,850	$134.00	$83,510.01	$85,510
$134.00	$81,690.01	$83,690	$136.00	$83,850.01	$85,850	$138.00	$85,510.01	$87,510
$138.00	$83,690.01	$85,690	$140.00	$85,850.01	$87,850	$142.00	$87,510.01	$89,510
$143.00	$85,690.01	$87,690	$144.00	$87,850.01	$89,850	$146.00	$89,510.01	$91,510
$148.00	$87,690.01	$89,690	$149.00	$89,850.01	$91,850	$150.00	$91,510.01	$93,510
$153.00	$89,690.01	$91,690	$154.00	$91,850.01	$93,850	$154.00	$93,510.01	$95,510
$158.00	$91,690.01	$93,690	$159.00	$93,850.01	$95,850	$159.00	$95,510.01	$97,510
$163.00	$93,690.01	$95,690	$164.00	$95,850.01	$97,850	$164.00	$97,510.01	$99,510
$168.00	$95,690.01	$97,690	$169.00	$97,850.01	$99,850	$169.00	$99,510.01	$101,510
$173.00	$97,690.01	$99,690	$174.00	$99,850.01	$101,850	$174.00	$101,510.01	$103,510
$178.00	$99,690.01	$101,690	$179.00	$101,850.01	$103,850	$179.00	$103,510.01	$105,510
$183.00	$101,690.01	$103,690	$184.00	$103,850.01	$105,850	$184.00	$105,510.01	$107,510
$188.00	$103,690.01	$105,690	$189.00	$105,850.01	$107,850	$189.00	$107,510.01	$109,510
$193.00	$105,690.01	$107,690	$194.00	$107,850.01	$109,850	$194.00	$109,510.01	$111,510
$198.00	$107,690.01	$109,690	$199.00	$109,850.01	$111,850	$199.00	$111,510.01	$113,510
$203.00	$109,690.01	$111,690	$204.00	$111,850.01	$113,850	$204.00	$113,510.01	$115,510
$208.00	$111,690.01	$113,690	$209.00	$113,850.01	$115,850	$209.00	$115,510.01	$117,510
$213.00	$113,690.01	$115,690	$214.00	$115,850.01	$117,850	$214.00	$117,510.01	$119,510
$218.00	$115,690.01	$117,690	$219.00	$117,850.01	$119,850	$219.00	$119,510.01	$121,510
$224.00	$117,690.01	$119,690	$224.00	$119,850.01	$121,850	$224.00	$121,510.01	$123,510
$230.00	$119,690.01	$121,690	$229.00	$121,850.01	$123,850	$229.00	$123,510.01	$125,510
$236.00	$121,690.01	$123,690	$235.00	$123,850.01	$125,850	$234.00	$125,510.01	$127,510
$242.00	$123,690.01	$125,690	$241.00	$125,850.01	$127,850	$239.00	$127,510.01	$129,510
$248.00	$125,690.01	$127,690	$247.00	$127,850.01	$129,850	$244.00	$129,510.01	$131,510
$254.00	$127,690.01	$129,690	$253.00	$129,850.01	$131,850	$250.00	$131,510.01	$133,510
$260.00	$129,690.01	$131,690	$259.00	$131,850.01	$133,850	$256.00	$133,510.01	$135,510
$266.00	$131,690.01	$133,690	$265.00	$133,850.01	$135,850	$262.00	$135,510.01	$137,510
$272.00	$133,690.01	$135,690	$271.00	$135,850.01	$137,850	$268.00	$137,510.01	$139,510
$278.00	$135,690.01	$137,690	$277.00	$137,850.01	$139,850	$274.00	$139,510.01	$141,510
$284.00	$137,690.01	$139,690	$283.00	$139,850.01	$141,850	$280.00	$141,510.01	$143,510
$290.00	$139,690.01	$141,690	$289.00	$141,850.01	$143,850	$286.00	$143,510.01	$145,510
$297.00	$141,690.01	$143,690	$295.00	$143,850.01	$145,850	$292.00	$145,510.01	$147,510
			$301.00	$145,850.01	$147,850	$298.00	$147,510.01	$149,510
			$307.00	$147,850.01	$149,850	$304.00	$149,510.01	$151,510
			$314.00	$149,850.01	$154,748	$310.00	$151,510.01	$153,510
						$316.00	$153,510.01	$155,510
						$322.00	$155,510.01	$157,510
						$328.00	$157,510.01	$159,510
						$334.00	$159,510.01	$161,510
						$339.00	$161,510.01	$163,510
	200% FPIG	$123,380		200% FPIG	$131,700		200% FPIG	$140,020

Weekly	Family Size:	16	Weekly	Family Size:	17	Weekly	Family Size:	18
Co-pay	Annual Income		Co-pay	Annual Income		Co-pay	Annual Income
$5.00	Less than:	$8,660	$5.00	Less than:	$8,660	$5.00	Less than:	$8,660
$10.00	$8,660.01	$29,430	$10.00	$8,660.01	$29,410	$10.00	$8,660.01	$30,000
$34.00	$29,430.01	$38,070	$34.00	$29,410.01	$37,000	$35.00	$30,000.01	$38,500
$44.00	$38,070.01	$43,170	$43.00	$37,000.01	$46,330	$45.00	$38,500.01	$47,490
$50.00	$43,170.01	$45,170	$54.00	$46,330.01	$48,330	$56.00	$47,490.01	$49,490
$53.00	$45,170.01	$47,170	$57.00	$48,330.01	$50,330	$59.00	$49,490.01	$51,490
$57.00	$47,170.01	$49,170	$61.00	$50,330.01	$52,330	$62.00	$51,490.01	$53,490
$61.00	$49,170.01	$51,170	$65.00	$52,330.01	$54,330	$66.00	$53,490.01	$55,490
$65.00	$51,170.01	$53,170	$69.00	$54,330.01	$56,330	$70.00	$55,490.01	$57,490
$69.00	$53,170.01	$55,170	$73.00	$56,330.01	$58,330	$74.00	$57,490.01	$59,490
$73.00	$55,170.01	$57,170	$77.00	$58,330.01	$60,330	$78.00	$59,490.01	$61,490
$77.00	$57,170.01	$59,170	$81.00	$60,330.01	$62,330	$82.00	$61,490.01	$63,490
$81.00	$59,170.01	$61,170	$85.00	$62,330.01	$64,330	$86.00	$63,490.01	$65,490
$85.00	$61,170.01	$63,170	$89.00	$64,330.01	$66,330	$90.00	$65,490.01	$67,490
$89.00	$63,170.01	$65,170	$93.00	$66,330.01	$68,330	$94.00	$67,490.01	$69,490
$93.00	$65,170.01	$67,170	$97.00	$68,330.01	$70,330	$98.00	$69,490.01	$71,490
$98.00	$67,170.01	$69,170	$101.00	$70,330.01	$72,330	$102.00	$71,490.01	$73,490
$103.00	$69,170.01	$71,170	$106.00	$72,330.01	$74,330	$106.00	$73,490.01	$75,490
$108.00	$71,170.01	$74,170	$111.00	$74,330.01	$76,330	$111.00	$75,490.01	$77,490
$113.00	$74,170.01	$76,170	$116.00	$76,330.01	$78,330	$116.00	$77,490.01	$79,490
$117.00	$76,170.01	$77,570	$120.00	$78,330.01	$80,330	$121.00	$79,490.01	$82,490
$120.00	$77,570.01	$79,570	$124.00	$80,330.01	$82,330	$126.00	$82,490.01	$83,490
$124.00	$79,570.01	$81,570	$128.00	$82,330.01	$84,330	$128.00	$83,490.01	$85,490
$128.00	$81,570.01	$83,570	$132.00	$84,330.01	$86,330	$132.00	$85,490.01	$87,490
$132.00	$83,570.01	$85,570	$136.00	$86,330.01	$88,330	$136.00	$87,490.01	$89,490
$136.00	$85,570.01	$87,570	$140.00	$88,330.01	$90,330	$140.00	$89,490.01	$91,490
$140.00	$87,570.01	$89,570	$144.00	$90,330.01	$92,330	$144.00	$91,490.01	$93,490
$144.00	$89,570.01	$91,570	$148.00	$92,330.01	$94,330	$148.00	$93,490.01	$95,490
$148.00	$91,570.01	$93,570	$152.00	$94,330.01	$96,330	$152.00	$95,490.01	$97,490
$152.00	$93,570.01	$95,570	$156.00	$96,330.01	$98,330	$156.00	$97,490.01	$99,490
$156.00	$95,570.01	$97,570	$160.00	$98,330.01	$100,330	$160.00	$99,490.01	$101,490
$160.00	$97,570.01	$99,570	$164.00	$100,330.01	$102,330	$164.00	$101,490.01	$103,490
$164.00	$99,570.01	$101,570	$168.00	$102,330.01	$104,330	$168.00	$103,490.01	$105,490
$169.00	$101,570.01	$103,570	$173.00	$104,330.01	$106,330	$172.00	$105,490.01	$107,490
$174.00	$103,570.01	$105,570	$178.00	$106,330.01	$108,330	$176.00	$107,490.01	$109,490
$179.00	$105,570.01	$107,570	$183.00	$108,330.01	$110,330	$180.00	$109,490.01	$111,490
$184.00	$107,570.01	$109,570	$188.00	$110,330.01	$112,330	$185.00	$111,490.01	$113,490
$189.00	$109,570.01	$111,570	$193.00	$112,330.01	$114,330	$190.00	$113,490.01	$115,490
$194.00	$111,570.01	$113,570	$198.00	$114,330.01	$116,330	$195.00	$115,490.01	$117,490
$199.00	$113,570.01	$115,570	$203.00	$116,330.01	$118,330	$200.00	$117,490.01	$119,490
$204.00	$115,570.01	$117,570	$208.00	$118,330.01	$120,330	$205.00	$119,490.01	$121,490
$209.00	$117,570.01	$119,570	$213.00	$120,330.01	$122,330	$210.00	$121,490.01	$123,490
$214.00	$119,570.01	$121,570	$218.00	$122,330.01	$124,330	$215.00	$123,490.01	$125,490
$219.00	$121,570.01	$123,570	$223.00	$124,330.01	$126,330	$220.00	$125,490.01	$127,490
$224.00	$123,570.01	$125,570	$228.00	$126,330.01	$128,330	$225.00	$127,490.01	$129,490
$229.00	$125,570.01	$127,570	$233.00	$128,330.01	$130,330	$230.00	$129,490.01	$131,490
$234.00	$127,570.01	$129,570	$238.00	$130,330.01	$132,330	$235.00	$131,490.01	$133,490
$239.00	$129,570.01	$131,570	$243.00	$132,330.01	$134,330	$240.00	$133,490.01	$135,490
$244.00	$131,570.01	$133,570	$248.00	$134,330.01	$136,330	$245.00	$135,490.01	$137,490
$249.00	$133,570.01	$135,570	$253.00	$136,330.01	$138,330	$250.00	$137,490.01	$139,490
$254.00	$135,570.01	$137,570	$258.00	$138,330.01	$140,330	$255.00	$139,490.01	$141,490
$259.00	$137,570.01	$139,570	$263.00	$140,330.01	$142,330	$260.00	$141,490.01	$143,490
$264.00	$139,570.01	$141,570	$268.00	$142,330.01	$144,330	$265.00	$143,490.01	$145,490
$270.00	$141,570.01	$143,570	$273.00	$144,330.01	$146,330	$270.00	$145,490.01	$147,490
$276.00	$143,570.01	$145,570	$278.00	$146,330.01	$148,330	$275.00	$147,490.01	$149,490
$282.00	$145,570.01	$147,570	$284.00	$148,330.01	$150,330	$280.00	$149,490.01	$151,490
$288.00	$147,570.01	$149,570	$290.00	$150,330.01	$152,330	$285.00	$151,490.01	$153,490
$294.00	$149,570.01	$151,570	$296.00	$152,330.01	$154,330	$290.00	$153,490.01	$155,490
$300.00	$151,570.01	$153,570	$302.00	$154,330.01	$156,330	$296.00	$155,490.01	$157,490
$306.00	$153,570.01	$155,570	$308.00	$156,330.01	$158,330	$302.00	$157,490.01	$159,490
$312.00	$155,570.01	$157,570	$314.00	$158,330.01	$160,330	$308.00	$159,490.01	$161,490
$318.00	$157,570.01	$159,570	$320.00	$160,330.01	$162,330	$314.00	$161,490.01	$163,490
$324.00	$159,570.01	$161,570	$326.00	$162,330.01	$164,330	$320.00	$163,490.01	$165,490
$330.00	$161,570.01	$163,570	$332.00	$164,330.01	$166,330	$326.00	$165,490.01	$167,490
$336.00	$163,570.01	$165,570	$338.00	$166,330.01	$168,330	$332.00	$167,490.01	$169,490
$342.00	$165,570.01	$167,570	$344.00	$168,330.01	$170,330	$338.00	$169,490.01	$171,490
$348.00	$167,570.01	$169,570	$350.00	$170,330.01	$172,330	$344.00	$171,490.01	$173,490
$355.00	$169,570.01	$171,570	$356.00	$172,330.01	$174,330	$350.00	$173,490.01	$175,490
			$362.00	$174,330.01	$176,330	$356.00	$175,490.01	$177,490
			$368.00	$176,330.01	$178,330	$362.00	$177,490.01	$179,490
			$374.00	$178,330.01	$184,076	$368.00	$179,490.01	$181,490
						$374.00	$181,490.01	$183,490
						$380.00	$183,490.01	$185,490
						$386.00	$185,490.01	$187,490
						$392.00	$187,490.01	$189,490
						$397.00	$189,490.01	$191,490
	200% FPIG	$148,340		200% FPIG	$156,660		200% FPIG	$164,980

Weekly	Family Size:	19	Weekly	Family Size:	20	Weekly	Family Size:	21
Co-pay	Annual Income		Co-pay	Annual Income		Co-pay	Annual Income
$5.00	Less than:	$8,660	$5.00	Less than:	$8,660	$5.00	Less than:	$8,660
$10.00	$8,660.01	$30,300	$10.00	$8,660.01	$32,000	$10.00	$8,660.01	$34,640
$35.00	$30,300.01	$40,300	$37.00	$32,000.01	$41,330	$40.00	$34,640.01	$45,890
$47.00	$40,300.01	$48,750	$48.00	$41,330.01	$50,810	$53.00	$45,890.01	$53,640
$57.00	$48,750.01	$50,750	$59.00	$50,810.01	$52,810	$62.00	$53,640.01	$54,970
$60.00	$50,750.01	$52,750	$62.00	$52,810.01	$54,810	$64.00	$54,970.01	$56,970
$63.00	$52,750.01	$54,750	$65.00	$54,810.01	$56,810	$67.00	$56,970.01	$58,970
$66.00	$54,750.01	$56,750	$68.00	$56,810.01	$58,810	$70.00	$58,970.01	$60,970
$70.00	$56,750.01	$58,750	$72.00	$58,810.01	$60,810	$74.00	$60,970.01	$62,970
$74.00	$58,750.01	$60,750	$76.00	$60,810.01	$62,810	$78.00	$62,970.01	$64,970
$78.00	$60,750.01	$62,750	$80.00	$62,810.01	$64,810	$82.00	$64,970.01	$66,970
$82.00	$62,750.01	$64,750	$84.00	$64,810.01	$66,810	$86.00	$66,970.01	$68,970
$86.00	$64,750.01	$66,750	$88.00	$66,810.01	$68,810	$90.00	$68,970.01	$70,970
$90.00	$66,750.01	$68,750	$92.00	$68,810.01	$70,810	$94.00	$70,970.01	$72,970
$94.00	$68,750.01	$70,750	$96.00	$70,810.01	$72,810	$98.00	$72,970.01	$74,970
$98.00	$70,750.01	$72,750	$100.00	$72,810.01	$74,810	$102.00	$74,970.01	$76,970
$102.00	$72,750.01	$74,750	$104.00	$74,810.01	$76,810	$106.00	$76,970.01	$78,970
$106.00	$74,750.01	$76,750	$108.00	$76,810.01	$78,810	$110.00	$78,970.01	$80,970
$110.00	$76,750.01	$78,750	$112.00	$78,810.01	$80,810	$114.00	$80,970.01	$82,970
$114.00	$78,750.01	$80,750	$116.00	$80,810.01	$82,810	$118.00	$82,970.01	$84,970
$119.00	$80,750.01	$82,750	$120.00	$82,810.01	$84,810	$122.00	$84,970.01	$86,970
$124.00	$82,750.01	$84,750	$125.00	$84,810.01	$86,810	$126.00	$86,970.01	$88,970
$129.00	$84,750.01	$86,650	$130.00	$86,810.01	$88,810	$131.00	$88,970.01	$90,970
$133.00	$86,650.01	$88,750	$135.00	$88,810.01	$90,810	$136.00	$90,970.01	$92,970
$137.00	$88,750.01	$90,750	$139.00	$90,810.01	$92,810	$141.00	$92,970.01	$94,970
$141.00	$90,750.01	$92,750	$143.00	$92,810.01	$94,810	$145.00	$94,970.01	$96,970
$145.00	$92,750.01	$94,750	$147.00	$94,810.01	$96,810	$149.00	$96,970.01	$98,970
$149.00	$94,750.01	$96,750	$151.00	$96,810.01	$98,810	$153.00	$98,970.01	$100,970
$153.00	$96,750.01	$98,750	$155.00	$98,810.01	$100,810	$157.00	$100,970.01	$102,970
$157.00	$98,750.01	$100,750	$159.00	$100,810.01	$102,810	$161.00	$102,970.01	$104,970
$161.00	$100,750.01	$102,750	$163.00	$102,810.01	$104,810	$165.00	$104,970.01	$106,970
$165.00	$102,750.01	$104,750	$167.00	$104,810.01	$106,810	$169.00	$106,970.01	$108,970
$169.00	$104,750.01	$106,750	$171.00	$106,810.01	$108,810	$173.00	$108,970.01	$110,970
$173.00	$106,750.01	$108,750	$175.00	$108,810.01	$110,810	$177.00	$110,970.01	$112,970
$177.00	$108,750.01	$110,750	$179.00	$110,810.01	$112,810	$181.00	$112,970.01	$114,970
$181.00	$110,750.01	$112,750	$183.00	$112,810.01	$114,810	$185.00	$114,970.01	$116,970
$185.00	$112,750.01	$114,750	$187.00	$114,810.01	$116,810	$189.00	$116,970.01	$118,970
$189.00	$114,750.01	$116,750	$191.00	$116,810.01	$118,810	$193.00	$118,970.01	$120,970
$194.00	$116,750.01	$118,750	$195.00	$118,810.01	$120,810	$197.00	$120,970.01	$122,970
$199.00	$118,750.01	$120,750	$199.00	$120,810.01	$122,810	$201.00	$122,970.01	$124,970
$204.00	$120,750.01	$122,750	$204.00	$122,810.01	$124,810	$205.00	$124,970.01	$126,970
$209.00	$122,750.01	$124,750	$209.00	$124,810.01	$126,810	$210.00	$126,970.01	$128,970
$214.00	$124,750.01	$126,750	$214.00	$126,810.01	$128,810	$215.00	$128,970.01	$130,970
$219.00	$126,750.01	$128,750	$219.00	$128,810.01	$130,810	$220.00	$130,970.01	$132,970
$224.00	$128,750.01	$130,750	$224.00	$130,810.01	$132,810	$225.00	$132,970.01	$134,970
$229.00	$130,750.01	$132,750	$229.00	$132,810.01	$134,810	$230.00	$134,970.01	$136,970
$234.00	$132,750.01	$134,750	$234.00	$134,810.01	$136,810	$235.00	$136,970.01	$138,970
$239.00	$134,750.01	$136,750	$239.00	$136,810.01	$138,810	$240.00	$138,970.01	$140,970
$244.00	$136,750.01	$138,750	$244.00	$138,810.01	$140,810	$245.00	$140,970.01	$142,970
$249.00	$138,750.01	$140,750	$249.00	$140,810.01	$142,810	$250.00	$142,970.01	$144,970
$254.00	$140,750.01	$142,750	$254.00	$142,810.01	$144,810	$255.00	$144,970.01	$146,970
$259.00	$142,750.01	$144,750	$259.00	$144,810.01	$146,810	$260.00	$146,970.01	$148,970
$264.00	$144,750.01	$146,750	$264.00	$146,810.01	$148,810	$265.00	$148,970.01	$150,970
$269.00	$146,750.01	$148,750	$269.00	$148,810.01	$150,810	$270.00	$150,970.01	$152,970
$274.00	$148,750.01	$150,750	$274.00	$150,810.01	$152,810	$275.00	$152,970.01	$154,970
$279.00	$150,750.01	$152,750	$279.00	$152,810.01	$154,810	$280.00	$154,970.01	$156,970
$284.00	$152,750.01	$154,750	$284.00	$154,810.01	$156,810	$285.00	$156,970.01	$158,970
$289.00	$154,750.01	$156,750	$289.00	$156,810.01	$158,810	$290.00	$158,970.01	$160,970
$294.00	$156,750.01	$158,750	$294.00	$158,810.01	$160,810	$295.00	$160,970.01	$162,970
$299.00	$158,750.01	$160,750	$299.00	$160,810.01	$162,810	$300.00	$162,970.01	$164,970
$304.00	$160,750.01	$162,750	$304.00	$162,810.01	$164,810	$305.00	$164,970.01	$166,970
$309.00	$162,750.01	$164,750	$309.00	$164,810.01	$166,810	$310.00	$166,970.01	$168,970
$315.00	$164,750.01	$166,750	$314.00	$166,810.01	$168,810	$315.00	$168,970.01	$170,970
$321.00	$166,750.01	$168,750	$319.00	$168,810.01	$170,810	$320.00	$170,970.01	$172,970
$327.00	$168,750.01	$170,750	$324.00	$170,810.01	$172,810	$325.00	$172,970.01	$174,970
$333.00	$170,750.01	$172,750	$330.00	$172,810.01	$174,810	$330.00	$174,970.01	$176,970
$339.00	$172,750.01	$174,750	$336.00	$174,810.01	$176,810	$335.00	$176,970.01	$178,970
$345.00	$174,750.01	$176,750	$342.00	$176,810.01	$178,810	$341.00	$178,970.01	$180,970
$351.00	$176,750.01	$178,750	$348.00	$178,810.01	$180,810	$347.00	$180,970.01	$182,970
$357.00	$178,750.01	$180,750	$354.00	$180,810.01	$182,810	$353.00	$182,970.01	$184,970
$363.00	$180,750.01	$182,750	$360.00	$182,810.01	$184,810	$359.00	$184,970.01	$186,970
$369.00	$182,750.01	$184,750	$366.00	$184,810.01	$186,810	$365.00	$186,970.01	$188,970
$375.00	$184,750.01	$186,750	$372.00	$186,810.01	$188,810	$371.00	$188,970.01	$190,970
$381.00	$186,750.01	$188,750	$378.00	$188,810.01	$190,810	$377.00	$190,970.01	$192,970
$387.00	$188,750.01	$190,750	$384.00	$190,810.01	$192,810	$383.00	$192,970.01	$194,970
$393.00	$190,750.01	$192,750	$390.00	$192,810.01	$194,810	$389.00	$194,970.01	$196,970
$399.00	$192,750.01	$194,750	$396.00	$194,810.01	$196,810	$395.00	$196,970.01	$198,970
$405.00	$194,750.01	$196,750	$402.00	$196,810.01	$198,810	$401.00	$198,970.01	$200,970
$411.00	$196,750.01	$200,750	$408.00	$198,810.01	$200,810	$407.00	$200,970.01	$202,970
$421.00	$200,750.01	$203,000	$414.00	$200,810.01	$202,810	$413.00	$202,970.01	$204,970
$426.00	$203,000.01	$203,628	$420.00	$202,810.01	$204,810	$419.00	$204,970.01	$206,970
			$426.00	$204,810.01	$206,810	$425.00	$206,970.01	$208,970
			$432.00	$206,810.01	$208,810	$431.00	$208,970.01	$210,970
			$438.00	$208,810.01	$210,810	$437.00	$210,970.01	$212,970
						$443.00	$212,970.01	$214,970
						$449.00	$214,970.01	$216,970
						$455.00	$216,970.01	$223,180
	200% FPIG	$173,300		200% FPIG	$181,620		200% FPIG	$189,940

Source

The provisions of this Appendix B amended May 5, 2006, effective May 1, 2006, 36 Pa.B. 2238; amended June 29, 2007, effective June 30, 2007, 37 Pa.B. 3027; amended August 8, 2008, effective May 5, 2008, 38 Pa.B. 4441; amended May 15, 2009, effective May 4, 2009, 39 Pa.B. 2497; amended April 22, 2011, effective May 2, 2011, 41 Pa.B. 2172; amended September 30, 2011, effective October 3, 2011, 41 Pa.B. 5232; amended May 18, 2012, effective May 7, 2012, 42 Pa.B. 2853; amended May 3, 2013, effective May 6, 2013, 43 Pa.B. 2515; amended May 2, 2014, effective May 5, 2014, 44 Pa.B. 2715; amended May 1, 2015, effective May 4, 2015, 45 Pa.B. 2192. Immediately preceding text appears at serial pages (371722) to (371732).

Cross References

This section cited in 55 Pa. Code § 168.1 (relating to policy on payment of child care); 55 Pa. Code § 168.2 (relating to definitions); 55 Pa. Code § 168.74 (relating to determining weekly child care co-payment for the employed TANF budget group); 55 Pa. Code § 3041.107 (relating to availability and use of the Federal Poverty Income Guidelines); and 55 Pa. Code § 3041.108 (relating to co-payment for families headed by a parent).