Family Size 2 | |
Monthly Income | Monthly Co-Pay |
$0-1,703 | $1.00 |
1,704 - 1,874 | 18.00 |
1,875 - 2,044 | 39.00 |
2,045 - 2,214 | 64.00 |
2,215 - 2,385 | 92.00 |
2,386 - 2,555 | 124.00 |
2,556 - 2,725 | 158.00 |
2,726 - 2,896 | 197.00 |
2,897 - 3,066 | 209.00 |
3,067 - 3,236 | 221.00 |
3,237 - 3,407 | 233.00 |
3,408 - 3,577 | 245.00 |
3,578 - 3,747 | 256.00 |
3,748 - 3,833 | 265.00 |
3,834 - 3,918 | 271.00 |
3,919 - 4,088 | 280.00 |
4,089 - 4,258 | 292.00 |
4,259 - 4,429 | 304.00 |
4,430 - 4,599 | 316.00 |
4,600 - 4,684 | 325.00 |
4,685 - 5,427 | 325.00 |
Family Size 3 | |
Monthly Income | Monthly Co-Pay |
$0-2,152 | $1.00 |
2,153 - 2,367 | 23.00 |
2,368 - 2,582 | 50.00 |
2,583 - 2,797 | 81.00 |
2,798 - 3,012 | 116.00 |
3,013 - 3,228 | 156.00 |
3,229 - 3,443 | 200.00 |
3,444 - 3,658 | 249.00 |
3,659 - 3,873 | 264.00 |
3,874 - 4,088 | 279.00 |
4,089 - 4,303 | 294.00 |
4,304 - 4,519 | 309.00 |
4,520 - 4,734 | 324.00 |
4,735 - 4,841 | 335.00 |
4,842 - 4,949 | 343.00 |
4,950 - 5,164 | 354.00 |
5,165 - 5,379 | 369.00 |
5,380 - 5,594 | 384.00 |
5,595 - 5,810 | 399.00 |
5,811 - 5,917 | 410.00 |
5,918 - 6,704 | 410.00 |
Family Size 4 | |
Monthly Income | Monthly Co-Pay |
$0-2,600 | $1.00 |
2,601 - 2,860 | 27.00 |
2,861 - 3,120 | 60.00 |
3,121 - 3,380 | 98.00 |
3,381 - 3,640 | |
140.00 | |
3,641 - 3,900 | |
189.00 | |
3,901 - 4,160 | |
242.00 | |
4,161 - 4,420 | |
300.00 | |
4,421 - 4,680 | 319.00 |
4,681 - 4,940 | 337.00 |
4,941 - 5,200 | 355.00 |
5,201 - 5,460 | 373.00 |
5,461 - 5,720 | 391.00 |
5,721 - 5,850 | 405.00 |
5,851 - 5,980 | 414.00 |
5,981 - 6,240 | 428.00 |
6,241 - 6,500 | 446.00 |
6,501 - 6,760 | 464.00 |
6,761 - 7,020 | 482.00 |
7,021 - 7,150 | 496.00 |
7,151 - 7,981 | 496.00 |
Family Size 5 | |
Monthly Income | Monthly Co-Pay |
$0-3,048 | $1.00 |
3,049 - 3,353 | 32.00 |
3,354 - 3,658 | 70.00 |
3,659 - 3,963 | |
114.00 | |
3,964 - 4,268 | |
165.00 | |
4,269 - 4,573 | |
221.00 | |
4,574 - 4,877 | |
284.00 | |
4,878 - 5,182 | |
352.00 | |
5,183 - 5,487 | 373.00 |
5,488 - 5,792 | 395.00 |
5,793 - 6,097 | 416.00 |
6,098 - 6,402 | 438.00 |
6,403 - 6,706 | 459.00 |
6,707 - 6,859 | 475.00 |
6,860 - 7,011 | 486.00 |
7,012 - 7,316 | 501.00 |
7,317 - 7,621 | 523.00 |
7,622 - 7,926 | 544.00 |
7,927 - 8,231 | 566.00 |
8,232 - 8,383 | 582.00 |
8,384 - 9,258 | 582.00 |
Family Size 6 | |
Monthly Income | Monthly Co-Pay |
$0-3,497 | $1.00 |
3,498 - 3,846 | 37.00 |
3,847 - 4,196 | 80.00 |
4,197 - 4,546 | 131.00 |
4,547 - 4,895 | 189.00 |
4,896 - 5,245 | 254.00 |
5,246 - 5,595 | 325.00 |
5,596 - 5,944 | 404.00 |
5,945 - 6,294 | 428.00 |
6,295 - 6,644 | 453.00 |
6,645 - 6,993 | 477.00 |
6,994 - 7,343 | 502.00 |
7,344 - 7,693 | 526.00 |
7,694 - 7,868 | 545.00 |
7,869 - 8,042 | 557.00 |
8,043 - 8,392 | 575.00 |
8,393 - 8,742 | 600.00 |
8,743 - 9,091 | 624.00 |
9,092 - 9,441 | 649.00 |
9,442 - 9,616 | 667.00 |
9,617 - 10,535 | 667.00 |
Family Size 7 | |
Monthly Income | Monthly Co-Pay |
$0-3,945 | $1.00 |
3,946 - 4,340 | 41.00 |
4,341 - 4,734 | 91.00 |
4,735 - 5,129 | 148.00 |
5,130 - 5,523 | 213.00 |
5,524 - 5,918 | 286.00 |
5,919 - 6,312 | 367.00 |
6,313 - 6,707 | 456.00 |
6,708 - 7,101 | 483.00 |
7,102 - 7,496 | 511.00 |
7,497 - 7,890 | 539.00 |
7,891 - 8,285 | 566.00 |
8,286 - 8,679 | 594.00 |
8,680 - 8,876 | 614.00 |
8,877 - 9,074 | 628.00 |
9,075 - 9,468 | 649.00 |
9,469 - 9,863 | 677.00 |
9,864 - 10,257 | 704.00 |
10,258 - 10,652 | 732.00 |
10,653 - 10,775 | 753.00 |
Family Size 8 | |
Monthly Income | Monthly Co-Pay |
$0-4,393 | $1.00 |
4,394-4,833 | 46.00 |
4,834-5,272 | 101.00 |
5,273-5,711 | 165.00 |
5,712-6,151 | 237.00 |
6,152-6,590 | 319.00 |
6,591-7,029 | 409.00 |
7,030-7,469 | 508.00 |
7,470-7,908 | 538.00 |
7,909-8,347 | 569.00 |
8,348-8,787 | 600.00 |
8,788-9,226 | 630.00 |
9,227-9,665 | 661.00 |
9,666-9,885 | 684.00 |
9,886-10,105 | 700.00 |
10,106-10,544 | 723.00 |
10,545-10,983 | 753.00 |
10,984 - 11,014 | 784.00 |
Family Size 9 | |
Monthly Income | Monthly Co-Pay |
$0-4,842 | $1.00 |
4,843-5,326 | 51.00 |
5,327-5,810 | 111.00 |
5,811-6,294 | 182.00 |
6,295-6,778 | 261.00 |
6,779-7,263 | 351.00 |
7,264-7,747 | 450.00 |
7,748-8,231 | 559.00 |
8,232-8,715 | 593.00 |
8,716-9,199 | 627.00 |
9,200-9,683 | 661.00 |
9,684-10,168 | 695.00 |
10,169-10,652 | 729.00 |
10,653 - 10,894 | 754.00 |
10,895 - 11,136 | 771.00 |
11,137 - 11,254 | 797.00 |
Family Size 10 | |
Monthly Income | Monthly Co-Pay |
$0-5,290 | $1.00 |
5,291-5,819 | 56.00 |
5,820-6,348 | 122.00 |
6,349-6,877 | 198.00 |
6,878-7,406 | 286.00 |
7,407-7,935 | 384.00 |
7,936-8,464 | 492.00 |
8,465-8,993 | 611.00 |
8,994-9,522 | 648.00 |
9,523-10,051 | 685.00 |
10,052-10,580 | 722.00 |
10,581-11,109 | 759.00 |
11,110-11,493 | 796.00 |
Ill. Admin. Code tit. 89, § 50.320