Premiums and Copayments

$19,168 or less

$38,336 or less

$6.00

$72

$5.25

$19,169 to $20,205

$38,337 to $40,087

$12.08

$145

$6.65

$20,206 to $21,179

$40,088 to $41,736

$24.17

$290

$8.10

$21,180 to $22,214

$41,737 to $43,488

$36.17

$434

$9.75

$22,215 to $23,251

$43,489 to $45,240

$48.25

$579

$12.65

$23,252 to $24,286

$45,241 to $46,992

$60.33

$724

$14.10

$24,287 to $25,261

$46,993 to $48,640

$72.42

$869

$15.55

$25,262 to $26,297

$48,641 to $50,391

$84.50

$1,014

$17.05

$26,298 to $27,333

$50,392 to $52,143

$96.58

$1,159

$18.45

$27,334 to $28,369

$52,144 to $53,895

$108.58

$1,303

$19.95

$28,370 to $29,344

$53,896 to $55,545

$120.75

$1,449

$21.40

$29,345 to $30,379

$55,546 to $57,297

$132.75

$1,593

$22.85

$30,380 to $31,415

$57,298 to $59,049

$144.83

$1,738

$24.30

$31,416 to $32,450

$59,050 to $60,800

$156.83

$1,882

$25.75

$32,451 to $42,710

$60,801 to $77,213

$168.92

$2,027

$27.20

$42,711 to $52,968

$77,214 to $93,626

$181.08

$2,173

$28.70

$52,969 to $63,226

$93,627 to $110,039

$193.08

$2,317

$30.15

$63,227 to $73,485

$110,040 to $126,453

$205.17

$2,462

$31.60

$73,486 to $83,742

$126,454 to $142,866

$217.17

$2,606

$33.10

$83,743 to $94,001

$142,867 to $159,279

$229.33

$2,752

$34.50

Over $94,002

Over $159,280

$241.33

$2,896

$36.00