Premiums and Copayments

$18,307 or less

$36,615 or less

$5.50

$66

$4.00

$18,308 to $19,297

$36,616 to $38,287

$11.08

$133

$5.35

$19,298 to $20,228

$38,288 to $39,862

$22.17

$266

$6.70

$20,229 to $21,217

$39,863 to $41,535

$33.25

$399

$8.25

$21,218 to $22,206

$41,536 to $43,209

$44.33

$532

$11.00

$22,207 to $23,195

$43,210 to $44,882

$55.42

$665

$12.40

$23,196 to $24,126

$44,883 to $46,456

$66.50

$798

$13.75

$24,127 to $25,116

$46,457 to $48,129

$77.58

$931

$15.15

$25,117 to $26,105

$48,130 to $49,802

$88.67

$1,064

$16.50

$26,106 to $27,095

$49,803 to $51,475

$99.75

$1,197

$17.90

$27,096 to $28,026

$51,476 to $53,050

$110.83

$1,330

$19.25

$28,027 to $29,015

$53,051 to $54,723

$121.92

$1,463

$20.65

$29,016 to $30,004

$54,724 to $56,397

$133.00

$1,596

$22.00

$30,005 to $30,993

$56,398 to $58,069

$144.08

$1,729

$23.40

$30,994 to $40,791

$58,070 to $73,746

$155.17

$1,862

$24.75

$40,792 to $50,589

$73,747 to $89,422

$166.25

$1,995

$26.15

$50,590 to $60,387

$89,423 to $105,098

$177.33

$2,128

$27.55

$60,388 to $70,185

$105,099 to $120,775

$188.42

$2,261

$28.90

$70,186 to $79,982

$120,776 to $136,451

$199.50

$2,394

$30.30

$79,983 to $89,779

$136,452 to $152,127

$210.58

$2,527

$31.65

Over $89,779

Over $152,127

$221.67

$2,660

$33.05