Premiums and Copayments

$18,829 or less

$37,658 or less

$5.67

$68

$4.00

$18,830 to $19,847

$37,659 to $39,378

$11.42

$137

$5.35

$19,848 to $20,804

$39,379 to $40,998

$22.83

$274

$6.70

$20,805 to $21,821

$40,999 to $42,719

$34.17

$410

$8.25

$21,822 to $22,839

$42,720 to $44,440

$45.58

$547

$11.00

$22,840 to $23,856

$44,441 to $46,161

$57.00

$684

$12.40

$23,857 to $24,814

$46,162 to $47,779

$68.42

$821

$13.75

$24,815 to $25,832

$47,780 to $49,500

$79.83

$958

$15.15

$25,833 to $26,849

$49,501 to $51,221

$91.17

$1,094

$16.50

$26,850 to $27,867

$51,222 to $52,942

$102.58

$1,231

$17.90

$27,868 to $28,825

$52,943 to $54,562

$114.00

$1,368

$19.25

$28,826 to $29,841

$54,563 to $56,283

$125.42

$1,505

$20.65

$29,842 to $30,859

$56,284 to $58,004

$136.75

$1,641

$22.00

$30,860 to $31,876

$58,005 to $59,724

$148.17

$1,778

$23.40

$31,877 to $41,954

$59,725 to $75,847

$159.58

$1,915

$24.75

$41,955 to $52,031

$75,848 to $91,970

$171.00

$2,052

$26.15

$52,032 to $62,108

$91,971 to $108,093

$182.42

$2,189

$27.55

$62,109 to $72,185

$108,094 to $124,217

$193.75

$2,325

$28.90

$72,186 to $82,261

$124,218 to $140,339

$205.17

$2,462

$30.30

$82,262 to $92,338

$140,340 to $156,462

$216.58

$2,599

$31.65

Over $92,338

Over $156,462

$228.00

$2,736

$33.05