Premiums and Copayments

$17,144 or less

$34,290 or less

$5.50

$66

$4.00

$17,145 to $18,071

$34,291 to $35,856

$11.08

$133

$5.35

$18,072 to $18,943

$35,857 to $37,331

$22.17

$266

$6.70

$18,944 to $19,869

$37,332 to $38,898

$33.25

$399

$8.25

$19,870 to $20,796

$38,899 to $40,465

$44.33

$532

$11.00

$20,797 to $21,722

$40,466 to $42,032

$55.42

$665

$12.40

$21,723 to $22,594

$42,033 to $43,506

$66.50

$798

$13.75

$22,595 to $23,521

$43,507 to $45,073

$77.58

$931

$15.15

$23,522 to $24,447

$45,074 to $46,640

$88.67

$1,064

$16.50

$24,448 to $25,374

$46,641 to $48,207

$99.75

$1,197

$17.90

$25,375 to $26,246

$48,208 to $49,682

$110.83

$1,330

$19.25

$26,247 to $27,172

$49,683 to $51,249

$121.92

$1,463

$20.65

$27,173 to $28,099

$51,250 to $52,816

$133.00

$1,596

$22.00

$28,100 to $29,025

$52,817 to $54,382

$144.08

$1,729

$23.40

$29,026 to $38,201

$54,383 to $69,064

$155.17

$1,862

$24.75

$38,202 to $47,377

$69,065 to $83,745

$166.25

$1,995

$26.15

$47,378 to $56,553

$83,746 to $98,426

$177.33

$2,128

$27.55

$56,554 to $65,729

$98,427 to $113,108

$188.42

$2,261

$28.90

$65,730 to $74,904

$113,109 to $127,789

$199.50

$2,394

$30.30

$74,905 to $84,080

$127,790 to $142,470

$210.58

$2,527

$31.65

Over $84,080

Over $142,470

$221.67

$2,660

$33.05