Pa. Code tit. 55, pt. V, subpt. B, ch. 3042, OVERPAYMENT AND DISQUALIFICATION, app B
Current through Register Vol. 54, No. 44, November 2, 2024
Appendix B - Copayment ChartFamily Copayment Scale Effective January 17, 2022
(Based on the 2022 Federal Poverty Income Guidelines)
| Weekly Co-pay | Family Size: 1 Annual Income | Weekly Co-pay | Family Size: 2 Annual Income | Weekly Co-pay | Family Size: 3 Annual Income |
| $5 | Less than: | $7,567 | $5 | Less than: | $8,187 | $5 | Less than: | $7,741 |
| $6 | $7,567.01 | $8,324 | $6 | $8,187.41 | $9,211 | $6 | $7,741.01 | $9,031 |
| $7 | $8,323.71 | $9,080 | $7 | $9,210.84 | $10,234 | $7 | $9,031.01 | $10,321 |
| $8 | $9,080.41 | $9,837 | $8 | $10,234.26 | $11,258 | $8 | $10,321.01 | $11,611 |
| $9 | $9,837.11 | $10,594 | $9 | $11,257.69 | $12,281 | $9 | $11,611.01 | $12,902 |
| $9 | $10,593.81 | $11,351 | $10 | $12,281.11 | $13,305 | $10 | $12,902.01 | $14,192 |
| $10 | $11,350.51 | $12,107 | $12 | $13,304.54 | $14,328 | $12 | $14,192.01 | $15,482 |
| $11 | $12,107.21 | $12,864 | $13 | $14,327.96 | $15,351 | $13 | $15,482.01 | $16,772 |
| $12 | $12,863.91 | $13,621 | $14 | $15,351.39 | $16,375 | $15 | $16,772.01 | $18,062 |
| $13 | $13,620.61 | $14,377 | $15 | $16,374.81 | $17,398 | $16 | $18,062.01 | $19,352 |
| $14 | $14,377.31 | $15,134 | $17 | $17,398.24 | $18,422 | $18 | $19,352.01 | $20,642 |
| $15 | $15,134.01 | $15,891 | $18 | $18,421.66 | $19,445 | $19 | $20,642.01 | $21,933 |
| $16 | $15,890.71 | $16,647 | $19 | $19,445.09 | $20,469 | $21 | $21,933.01 | $23,223 |
| $17 | $16,647.41 | $17,404 | $21 | $20,468.51 | $21,492 | $23 | $23,223.01 | $24,513 |
| $19 | $17,404.11 | $18,161 | $22 | $21,491.94 | $22,515 | $24 | $24,513.01 | $25,803 |
| $20 | $18,160.81 | $18,918 | $24 | $22,515.36 | $23,539 | $26 | $25,803.01 | $27,093 |
| $21 | $18,917.51 | $19,674 | $25 | $23,538.79 | $24,562 | $28 | $27,093.01 | $28,383 |
| $22 | $19,674.21 | $20,431 | $27 | $24,562.21 | $25,586 | $30 | $28,383.01 | $29,673 |
| $23 | $20,430.91 | $21,188 | $28 | $25,585.64 | $26,609 | $32 | $29,673.01 | $30,964 |
| $24 | $21,187.61 | $21,944 | $30 | $26,609.06 | $27,632 | $34 | $30,964.01 | $32,254 |
| $26 | $21,944.31 | $22,701 | $31 | $27,632.49 | $28,656 | $36 | $32,254.01 | $33,544 |
| $27 | $22,701.01 | $23,458 | $33 | $28,655.91 | $29,679 | $38 | $33,544.01 | $34,834 |
| $28 | $23,457.71 | $24,214 | $35 | $29,679.34 | $30,703 | $40 | $34,834.01 | $36,124 |
| $30 | $24,214.41 | $24,971 | $36 | $30,702.76 | $31,726 | $42 | $36,124.01 | $37,414 |
| $31 | $24,971.11 | $25,728 | $38 | $31,726.19 | $32,750 | $44 | $37,414.01 | $38,705 |
| $32 | $25,727.81 | $26,485 | $40 | $32,749.61 | $33,773 | $46 | $38,705.01 | $39,995 |
| $34 | $26,484.51 | $27,241 | $42 | $33,773.04 | $34,796 | $48 | $39,995.01 | $41,285 |
| $35 | $27,241.21 | $27,998 | $44 | $34,796.46 | $35,820 | $51 | $41,285.01 | $42,575 |
| $37 | $27,997.91 | $28,755 | $46 | $35,819.89 | $36,843 | $53 | $42,575.01 | $43,865 |
| $38 | $28,754.61 | $29,511 | $48 | $36,843.31 | $37,867 | $55 | $43,865.01 | $45,155 |
| $40 | $29,511.31 | $30,268 | $50 | $37,866.74 | $38,890 | $58 | $45,155.01 | $46,445 |
| 200% FPIG | $25,760 | $52 | $38,890.16 | $39,914 | $60 | $46,445.01 | $47,736 |
| | | $54 | $39,913.59 | $40,937 | $63 | $47,736.01 | $49,026 |
| | | | 200% FPIG | $34,840 | $65 | $49,026.01 | $50,316 |
| | | | | | $68 | $50,316.01 | $51,606 |
| | | | | | | 200% FPIG | $43,920 |
| Weekly Co-pay | Family Size: 4 Annual Income | Weekly Co-pay | Family Size: 5 Annual Income | Weekly Co-pay | Family Size: 6 Annual Income |
| $5 | Less than: | $9,341 | $5 | Less than: | $9,118 | $5 | Less than: | $8,361 |
| $7 | $9,341.01 | $10,898 | $6 | $9,118.01 | $10,942 | $6 | $8,361.01 | $10,452 |
| $8 | $10,898.01 | $12,455 | $8 | $10,942.01 | $12,765 | $7 | $10,452.01 | $12,542 |
| $9 | $12,455.01 | $14,012 | $9 | $12,765.01 | $14,589 | $9 | $12,542.01 | $14,632 |
| $11 | $14,012.01 | $15,569 | $11 | $14,589.01 | $16,412 | $11 | $14,632.01 | $16,723 |
| $13 | $15,569.01 | $17,126 | $13 | $16,412.01 | $18,236 | $13 | $16,723.01 | $18,813 |
| $14 | $17,126.01 | $18,683 | $15 | $18,236.01 | $20,060 | $15 | $18,813.01 | $20,903 |
| $16 | $18,683.01 | $20,239 | $17 | $20,060.01 | $21,883 | $17 | $20,903.01 | $22,994 |
| $18 | $20,239.01 | $21,796 | $19 | $21,883.01 | $23,707 | $19 | $22,994.01 | $25,084 |
| $19 | $21,796.01 | $23,353 | $21 | $23,707.01 | $25,530 | $21 | $25,084.01 | $27,174 |
| $21 | $23,353.01 | $24,910 | $23 | $25,530.01 | $27,354 | $24 | $27,174.01 | $29,265 |
| $23 | $24,910.01 | $26,467 | $25 | $27,354.01 | $29,178 | $26 | $29,265.01 | $31,355 |
| $25 | $26,467.01 | $28,024 | $27 | $29,178.01 | $31,001 | $29 | $31,355.01 | $33,445 |
| $27 | $28,024.01 | $29,581 | $30 | $31,001.01 | $32,825 | $31 | $33,445.01 | $35,536 |
| $29 | $29,581.01 | $31,138 | $32 | $32,825.01 | $34,648 | $34 | $35,536.01 | $37,626 |
| $32 | $31,138.01 | $32,694 | $35 | $34,648.01 | $36,472 | $37 | $37,626.01 | $39,716 |
| $34 | $32,694.01 | $34,251 | $37 | $36,472.01 | $38,296 | $40 | $39,716.01 | $41,807 |
| $36 | $34,251.01 | $35,808 | $40 | $38,296.01 | $40,119 | $42 | $41,807.01 | $43,897 |
| $38 | $35,808.01 | $37,365 | $42 | $40,119.01 | $41,943 | $45 | $43,897.01 | $45,987 |
| $41 | $37,365.01 | $38,922 | $45 | $41,943.01 | $43,766 | $48 | $45,987.01 | $48,077 |
| $43 | $38,922.01 | $40,479 | $47 | $43,766.01 | $45,590 | $51 | $48,077.01 | $50,168 |
| $45 | $40,479.01 | $42,036 | $50 | $45,590.01 | $47,414 | $54 | $50,168.01 | $52,258 |
| $48 | $42,036.01 | $43,593 | $53 | $47,414.01 | $49,237 | $58 | $52,258.01 | $54,348 |
| $50 | $43,593.01 | $45,149 | $56 | $49,237.01 | $51,061 | $61 | $54,348.01 | $56,439 |
| $53 | $45,149.01 | $46,706 | $59 | $51,061.01 | $52,884 | $64 | $56,439.01 | $58,529 |
| $56 | $46,706.01 | $48,263 | $62 | $52,884.01 | $54,708 | $68 | $58,529.01 | $60,619 |
| $58 | $48,263.01 | $49,820 | $65 | $54,708.01 | $56,532 | $71 | $60,619.01 | $62,710 |
| $61 | $49,820.01 | $51,377 | $68 | $56,532.01 | $58,355 | $75 | $62,710.01 | $64,800 |
| $64 | $51,377.01 | $52,934 | $71 | $58,355.01 | $60,179 | $78 | $64,800.01 | $66,890 |
| $67 | $52,934.01 | $54,491 | $75 | $60,179.01 | $62,002 | $82 | $66,890.01 | $68,981 |
| $70 | $54,491.01 | $56,048 | $78 | $62,002.01 | $63,826 | $86 | $68,981.01 | $71,071 |
| $73 | $56,048.01 | $57,604 | $81 | $63,826.01 | $65,650 | $89 | $71,071.01 | $73,161 |
| $76 | $57,604.01 | $59,161 | $85 | $65,650.01 | $67,473 | $93 | $73,161.01 | $75,252 |
| $79 | $59,161.01 | $60,718 | $88 | $67,473.01 | $69,297 | $97 | $75,252.01 | $77,342 |
| $82 | $60,718.01 | $62,275 | $92 | $69,297.01 | $71,120 | $101 | $77,342.01 | $79,432 |
| 200% FPIG | $53,000 | $96 | $71,120.01 | $72,944 | $106 | $79,432.01 | $81,523 |
| | | | 200% FPIG | $62,080 | $110 | $81,523.01 | $83,613 |
| | | | | | | 200% FPIG | $71,160 |
| Weekly Co-pay | Family Size: 7 Annual Income | Weekly Co-pay | Family Size: 8 Annual Income | Weekly Co-pay | Family Size: 9 Annual Income |
| $5 | Less than: | $9,428 | $5 | Less than: | $10,495 | $5 | Less than: | $8,672 |
| $6 | $9,428.01 | $11,785 | $7 | $10,495.01 | $13,119 | $6 | $8,672.01 | $11,562 |
| $8 | $11,785.01 | $14,142 | $9 | $13,119.01 | $15,743 | $8 | $11,562.01 | $14,453 |
| $10 | $14,142.01 | $16,499 | $11 | $15,743.01 | $18,366 | $10 | $14,453.01 | $17,343 |
| $12 | $16,499.01 | $18,856 | $14 | $18,366.01 | $20,990 | $12 | $17,343.01 | $20,234 |
| $14 | $18,856.01 | $21,213 | $16 | $20,990.01 | $23,614 | $15 | $20,234.01 | $23,124 |
| $17 | $21,213.01 | $23,571 | $18 | $23,614.01 | $26,238 | $18 | $23,124.01 | $26,015 |
| $19 | $23,571.01 | $25,928 | $21 | $26,238.01 | $28,862 | $20 | $26,015.01 | $28,905 |
| $21 | $25,928.01 | $28,285 | $24 | $28,862.01 | $31,485 | $23 | $28,905.01 | $31,796 |
| $24 | $28,285.01 | $30,642 | $27 | $31,485.01 | $34,109 | $26 | $31,796.01 | $34,686 |
| $27 | $30,642.01 | $32,999 | $30 | $34,109.01 | $36,733 | $29 | $34,686.01 | $37,577 |
| $29 | $32,999.01 | $35,356 | $33 | $36,733.01 | $39,357 | $33 | $37,577.01 | $40,467 |
| $32 | $35,356.01 | $37,713 | $36 | $39,357.01 | $41,980 | $36 | $40,467.01 | $43,358 |
| $35 | $37,713.01 | $40,070 | $39 | $41,980.01 | $44,604 | $40 | $43,358.01 | $46,248 |
| $39 | $40,070.01 | $42,427 | $43 | $44,604.01 | $47,228 | $43 | $46,248.01 | $49,139 |
| $42 | $42,427.01 | $44,784 | $46 | $47,228.01 | $49,852 | $47 | $49,139.01 | $52,029 |
| $45 | $44,784.01 | $47,141 | $50 | $49,852.01 | $52,476 | $51 | $52,029.01 | $54,920 |
| $48 | $47,141.01 | $49,498 | $53 | $52,476.01 | $55,099 | $55 | $54,920.01 | $57,810 |
| $51 | $49,498.01 | $51,855 | $57 | $55,099.01 | $57,723 | $59 | $57,810.01 | $60,701 |
| $54 | $51,855.01 | $54,212 | $61 | $57,723.01 | $60,347 | $63 | $60,701.01 | $63,591 |
| $58 | $54,212.01 | $56,569 | $64 | $60,347.01 | $62,971 | $67 | $63,591.01 | $66,482 |
| $61 | $56,569.01 | $58,926 | $68 | $62,971.01 | $65,594 | $71 | $66,482.01 | $69,372 |
| $65 | $58,926.01 | $61,283 | $72 | $65,594.01 | $68,218 | $75 | $69,372.01 | $72,263 |
| $69 | $61,283.01 | $63,640 | $76 | $68,218.01 | $70,842 | $80 | $72,263.01 | $75,153 |
| $72 | $63,640.01 | $65,997 | $81 | $70,842.01 | $73,466 | $84 | $75,153.01 | $78,044 |
| $76 | $65,997.01 | $68,354 | $85 | $73,466.01 | $76,089 | $89 | $78,044.01 | $80,934 |
| $80 | $68,354.01 | $70,712 | $89 | $76,089.01 | $78,713 | $93 | $80,934.01 | $83,825 |
| $84 | $70,712.01 | $73,069 | $94 | $78,713.01 | $81,337 | $98 | $83,825.01 | $86,715 |
| $88 | $73,069.01 | $75,426 | $98 | $81,337.01 | $83,961 | $103 | $86,715.01 | $89,606 |
| $92 | $75,426.01 | $77,783 | $103 | $83,961.01 | $86,585 | $108 | $89,606.01 | $92,496 |
| $97 | $77,783.01 | $80,140 | $107 | $86,585.01 | $89,208 | $113 | $92,496.01 | $95,387 |
| $101 | $80,140.01 | $82,497 | $112 | $89,208.01 | $91,832 | $118 | $95,387.01 | $98,277 |
| $105 | $82,497.01 | $84,854 | $117 | $91,832.01 | $94,456 | $124 | $98,277.01 | $101,168 |
| $110 | $84,854.01 | $87,211 | $122 | $94,456.01 | $97,080 | $129 | $101,168.01 | $104,058 |
| $114 | $87,211.01 | $89,568 | $127 | $97,080.01 | $99,703 | $135 | $104,058.01 | $106,949 |
| $119 | $89,568.01 | $91,925 | $132 | $99,703.01 | $102,327 | $140 | $106,949.01 | $109,839 |
| $124 | $91,925.01 | $94,282 | $138 | $102,327.01 | $104,951 | $146 | $109,839.01 | $112,730 |
| 200% FPIG | $80,240 | | 200% FPIG | $89,320 | $152 | $112,730.01 | $115,620 |
| | | | | | | 200% FPIG | $98,400 |
| Weekly Co-pay | Family Size: 10 Annual Income | Weekly Co-pay | Family Size: 11 Annual Income | Weekly Co-pay | Family Size: 12 Annual Income |
| $5 | Less than: | $9,472 | $5 | Less than: | $10,272 | $5 | Less than: | $11,072 |
| $6 | $9,472.01 | $12,629 | $7 | $10,272.01 | $13,696 | $7 | $11,072.01 | $14,763 |
| $8 | $12,629.01 | $15,786 | $9 | $13,696.01 | $17,120 | $10 | $14,763.01 | $18,453 |
| $11 | $15,786.01 | $18,943 | $12 | $17,120.01 | $20,544 | $13 | $18,453.01 | $22,144 |
| $14 | $18,943.01 | $22,101 | $15 | $20,544.01 | $23,968 | $16 | $22,144.01 | $25,835 |
| $16 | $22,101.01 | $25,258 | $18 | $23,968.01 | $27,392 | $19 | $25,835.01 | $29,525 |
| $19 | $25,258.01 | $28,415 | $21 | $27,392.01 | $30,816 | $22 | $29,525.01 | $33,216 |
| $22 | $28,415.01 | $31,572 | $24 | $30,816.01 | $34,240 | $26 | $33,216.01 | $36,907 |
| $25 | $31,572.01 | $34,729 | $28 | $34,240.01 | $37,663 | $30 | $36,907.01 | $40,597 |
| $29 | $34,729.01 | $37,887 | $31 | $37,663.01 | $41,087 | $34 | $40,597.01 | $44,288 |
| $32 | $37,887.01 | $41,044 | $35 | $41,087.01 | $44,511 | $38 | $44,288.01 | $47,979 |
| $36 | $41,044.01 | $44,201 | $39 | $44,511.01 | $47,935 | $42 | $47,979.01 | $51,669 |
| $40 | $44,201.01 | $47,358 | $43 | $47,935.01 | $51,359 | $46 | $51,669.01 | $55,360 |
| $43 | $47,358.01 | $50,516 | $47 | $51,359.01 | $54,783 | $51 | $55,360.01 | $59,051 |
| $47 | $50,516.01 | $53,673 | $51 | $54,783.01 | $58,207 | $55 | $59,051.01 | $62,741 |
| $52 | $53,673.01 | $56,830 | $56 | $58,207.01 | $61,631 | $60 | $62,741.01 | $66,432 |
| $56 | $56,830.01 | $59,987 | $60 | $61,631.01 | $65,055 | $65 | $66,432.01 | $70,123 |
| $60 | $59,987.01 | $63,145 | $65 | $65,055.01 | $68,479 | $70 | $70,123.01 | $73,814 |
| $64 | $63,145.01 | $66,302 | $69 | $68,479.01 | $71,903 | $75 | $73,814.01 | $77,504 |
| $68 | $66,302.01 | $69,459 | $74 | $71,903.01 | $75,327 | $80 | $77,504.01 | $81,195 |
| $73 | $69,459.01 | $72,616 | $79 | $75,327.01 | $78,751 | $85 | $81,195.01 | $84,886 |
| $77 | $72,616.01 | $75,773 | $84 | $78,751.01 | $82,175 | $91 | $84,886.01 | $88,576 |
| $82 | $75,773.01 | $78,931 | $89 | $82,175.01 | $85,599 | $96 | $88,576.01 | $92,267 |
| $87 | $78,931.01 | $82,088 | $94 | $85,599.01 | $89,023 | $102 | $92,267.01 | $95,958 |
| $92 | $82,088.01 | $85,245 | $100 | $89,023.01 | $92,447 | $107 | $95,958.01 | $99,648 |
| $97 | $85,245.01 | $88,402 | $105 | $92,447.01 | $95,871 | $113 | $99,648.01 | $103,339 |
| $102 | $88,402.01 | $91,560 | $111 | $95,871.01 | $99,295 | $119 | $103,339.01 | $107,030 |
| $107 | $91,560.01 | $94,717 | $116 | $99,295.01 | $102,719 | $125 | $107,030.01 | $110,720 |
| $113 | $94,717.01 | $97,874 | $122 | $102,719.01 | $106,142 | $132 | $110,720.01 | $114,411 |
| $118 | $97,874.01 | $101,031 | $128 | $106,142.01 | $109,566 | $138 | $114,411.01 | $118,102 |
| $124 | $101,031.01 | $104,188 | $134 | $109,566.01 | $112,990 | $145 | $118,102.01 | $121,792 |
| $129 | $104,188.01 | $107,346 | $140 | $112,990.01 | $116,414 | $151 | $121,792.01 | $125,483 |
| $135 | $107,346.01 | $110,503 | $147 | $116,414.01 | $119,838 | $158 | $125,483.01 | $129,174 |
| $141 | $110,503.01 | $113,660 | $153 | $119,838.01 | $123,262 | $165 | $129,174.01 | $132,864 |
| $147 | $113,660.01 | $116,817 | $159 | $123,262.01 | $126,686 | $172 | $132,864.01 | $136,555 |
| $153 | $116,817.01 | $119,975 | $166 | $126,686.01 | $130,110 | $179 | $136,555.01 | $140,246 |
| $159 | $119,975.01 | $123,132 | $173 | $130,110.01 | $133,534 | $186 | $140,246.01 | $143,936 |
| $166 | $123,132.01 | $126,289 | $180 | $133,534.01 | $136,958 | $194 | $143,936.01 | $147,627 |
| 200% FPIG | $107,480 | | 200% FPIG | $116,560 | | 200% FPIG | $125,640 |
| Weekly Co-pay | Family Size: 13 Annual Income | Weekly Co-pay | Family Size: 14 Annual Income | Weekly Co-pay | Family Size: 15 Annual Income |
| $5 | Less than: | $11,872 | $5 | Less than: | $12,672 | $5 | Less than: | $8,982 |
| $8 | $11,872.01 | $15,830 | $8 | $12,672.01 | $16,897 | $6 | $8,982.01 | $13,473 |
| $11 | $15,830.01 | $19,787 | $11 | $16,897.01 | $21,121 | $9 | $13,473.01 | $17,963 |
| $14 | $19,787.01 | $23,744 | $15 | $21,121.01 | $25,345 | $12 | $17,963.01 | $22,454 |
| $17 | $23,744.01 | $27,702 | $18 | $25,345.01 | $29,569 | $15 | $22,454.01 | $26,945 |
| $20 | $27,702.01 | $31,659 | $22 | $29,569.01 | $33,793 | $19 | $26,945.01 | $31,436 |
| $24 | $31,659.01 | $35,617 | $26 | $33,793.01 | $38,017 | $23 | $31,436.01 | $35,927 |
| $28 | $35,617.01 | $39,574 | $30 | $38,017.01 | $42,241 | $27 | $35,927.01 | $40,418 |
| $32 | $39,574.01 | $43,531 | $34 | $42,241.01 | $46,465 | $32 | $40,418.01 | $44,909 |
| $36 | $43,531.01 | $47,489 | $38 | $46,465.01 | $50,690 | $36 | $44,909.01 | $49,399 |
| $40 | $47,489.01 | $51,446 | $43 | $50,690.01 | $54,914 | $41 | $49,399.01 | $53,890 |
| $45 | $51,446.01 | $55,404 | $48 | $54,914.01 | $59,138 | $46 | $53,890.01 | $58,381 |
| $50 | $55,404.01 | $59,361 | $53 | $59,138.01 | $63,362 | $51 | $58,381.01 | $62,872 |
| $54 | $59,361.01 | $63,318 | $58 | $63,362.01 | $67,586 | $56 | $62,872.01 | $67,363 |
| $59 | $63,318.01 | $67,276 | $63 | $67,586.01 | $71,810 | $62 | $67,363.01 | $71,854 |
| $65 | $67,276.01 | $71,233 | $69 | $71,810.01 | $76,034 | $67 | $71,854.01 | $76,344 |
| $70 | $71,233.01 | $75,191 | $74 | $76,034.01 | $80,258 | $73 | $76,344.01 | $80,835 |
| $75 | $75,191.01 | $79,148 | $80 | $80,258.01 | $84,483 | $79 | $80,835.01 | $85,326 |
| $80 | $79,148.01 | $83,105 | $86 | $84,483.01 | $88,707 | $85 | $85,326.01 | $89,817 |
| $86 | $83,105.01 | $87,063 | $91 | $88,707.01 | $92,931 | $91 | $89,817.01 | $94,308 |
| $91 | $87,063.01 | $91,020 | $97 | $92,931.01 | $97,155 | $97 | $94,308.01 | $98,799 |
| $97 | $91,020.01 | $94,978 | $104 | $97,155.01 | $101,379 | $104 | $98,799.01 | $103,290 |
| $103 | $94,978.01 | $98,935 | $110 | $101,379.01 | $105,603 | $110 | $103,290.01 | $107,780 |
| $109 | $98,935.01 | $102,892 | $116 | $105,603.01 | $109,827 | $117 | $107,780.01 | $112,271 |
| $115 | $102,892.01 | $106,850 | $123 | $109,827.01 | $114,051 | $124 | $112,271.01 | $116,762 |
| $121 | $106,850.01 | $110,807 | $130 | $114,051.01 | $118,276 | $131 | $116,762.01 | $121,253 |
| $128 | $110,807.01 | $114,765 | $136 | $118,276.01 | $122,500 | $138 | $121,253.01 | $125,744 |
| $134 | $114,765.01 | $118,722 | $143 | $122,500.01 | $126,724 | $145 | $125,744.01 | $130,235 |
| $141 | $118,722.01 | $122,679 | $151 | $126,724.01 | $130,948 | $153 | $130,235.01 | $134,726 |
| $148 | $122,679.01 | $126,637 | $158 | $130,948.01 | $135,172 | $160 | $134,726.01 | $139,216 |
| $155 | $126,637.01 | $130,594 | $165 | $135,172.01 | $139,396 | $168 | $139,216.01 | $143,707 |
| $162 | $130,594.01 | $134,552 | $173 | $139,396.01 | $143,620 | $176 | $143,707.01 | $148,198 |
| $169 | $134,552.01 | $138,509 | $181 | $143,620.01 | $147,844 | $184 | $148,198.01 | $152,689 |
| $177 | $138,509.01 | $142,466 | $189 | $147,844.01 | $152,069 | $192 | $152,689.01 | $157,180 |
| $184 | $142,466.01 | $146,424 | $197 | $152,069.01 | $156,293 | $201 | $157,180.01 | $161,671 |
| $192 | $146,424.01 | $150,381 | $205 | $156,293.01 | $160,517 | $209 | $161,671.01 | $166,161 |
| $200 | $150,381.01 | $154,339 | $213 | $160,517.01 | $164,741 | $218 | $166,161.01 | $170,652 |
| $208 | $154,339.01 | $158,296 | $222 | $164,741.01 | $168,965 | $227 | $170,652.01 | $175,143 |
| 200% FPIG | $134,720 | | 200% FPIG | $143,800 | $236 | $175,143.01 | $179,634 |
| | | | | | | 200% FPIG | $152,880 |
| Weekly Co-pay | Family Size: 16 Annual Income | Weekly Co-pay | Family Size: 17 Annual Income | Weekly Co-pay | Family Size: 18 Annual Income |
| $5 | Less than: | $9,515 | $5 | Less than: | $10,049 | $5 | Less than: | $10,582 |
| $6 | $9,515.01 | $14,273 | $6 | $10,049.01 | $15,073 | $7 | $10,582.01 | $15,873 |
| $9 | $14,273.01 | $19,030 | $10 | $15,073.01 | $20,097 | $10 | $15,873.01 | $21,164 |
| $13 | $19,030.01 | $23,788 | $13 | $20,097.01 | $25,122 | $14 | $21,164.01 | $26,455 |
| $16 | $23,788.01 | $28,545 | $17 | $25,122.01 | $30,146 | $18 | $26,455.01 | $31,746 |
| $20 | $28,545.01 | $33,303 | $21 | $30,146.01 | $35,170 | $23 | $31,746.01 | $37,037 |
| $24 | $33,303.01 | $38,061 | $26 | $35,170.01 | $40,194 | $27 | $37,037.01 | $42,328 |
| $29 | $38,061.01 | $42,818 | $30 | $40,194.01 | $45,219 | $32 | $42,328.01 | $47,619 |
| $33 | $42,818.01 | $47,576 | $35 | $45,219.01 | $50,243 | $37 | $47,619.01 | $52,910 |
| $38 | $47,576.01 | $52,333 | $40 | $50,243.01 | $55,267 | $42 | $52,910.01 | $58,201 |
| $43 | $52,333.01 | $57,091 | $46 | $55,267.01 | $60,292 | $48 | $58,201.01 | $63,492 |
| $48 | $57,091.01 | $61,848 | $51 | $60,292.01 | $65,316 | $54 | $63,492.01 | $68,783 |
| $54 | $61,848.01 | $66,606 | $57 | $65,316.01 | $70,340 | $60 | $68,783.01 | $74,074 |
| $60 | $66,606.01 | $71,364 | $63 | $70,340.01 | $75,365 | $66 | $74,074.01 | $79,365 |
| $65 | $71,364.01 | $76,121 | $69 | $75,365.01 | $80,389 | $73 | $79,365.01 | $84,656 |
| $71 | $76,121.01 | $80,879 | $75 | $80,389.01 | $85,413 | $79 | $84,656.01 | $89,947 |
| $78 | $80,879.01 | $85,636 | $82 | $85,413.01 | $90,437 | $86 | $89,947.01 | $95,238 |
| $84 | $85,636.01 | $90,394 | $89 | $90,437.01 | $95,462 | $93 | $95,238.01 | $100,529 |
| $90 | $90,394.01 | $95,152 | $95 | $95,462.01 | $100,486 | $100 | $100,529.01 | $105,821 |
| $96 | $95,152.01 | $99,909 | $102 | $100,486.01 | $105,510 | $107 | $105,821.01 | $111,112 |
| $103 | $99,909.01 | $104,667 | $109 | $105,510.01 | $110,535 | $115 | $111,112.01 | $116,403 |
| $110 | $104,667.01 | $109,424 | $116 | $110,535.01 | $115,559 | $122 | $116,403.01 | $121,694 |
| $117 | $109,424.01 | $114,182 | $123 | $115,559.01 | $120,583 | $130 | $121,694.01 | $126,985 |
| $124 | $114,182.01 | $118,939 | $131 | $120,583.01 | $125,608 | $138 | $126,985.01 | $132,276 |
| $131 | $118,939.01 | $123,697 | $138 | $125,608.01 | $130,632 | $146 | $132,276.01 | $137,567 |
| $138 | $123,697.01 | $128,455 | $146 | $130,632.01 | $135,656 | $154 | $137,567.01 | $142,858 |
| $146 | $128,455.01 | $133,212 | $154 | $135,656.01 | $140,680 | $162 | $142,858.01 | $148,149 |
| $154 | $133,212.01 | $137,970 | $162 | $140,680.01 | $145,705 | $171 | $148,149.01 | $153,440 |
| $162 | $137,970.01 | $142,727 | $171 | $145,705.01 | $150,729 | $180 | $153,440.01 | $158,731 |
| $170 | $142,727.01 | $147,485 | $179 | $150,729.01 | $155,753 | $189 | $158,731.01 | $164,022 |
| $178 | $147,485.01 | $152,242 | $188 | $155,753.01 | $160,778 | $198 | $164,022.01 | $169,313 |
| $186 | $152,242.01 | $157,000 | $197 | $160,778.01 | $165,802 | $207 | $169,313.01 | $174,604 |
| $195 | $157,000.01 | $161,758 | $206 | $165,802.01 | $170,826 | $217 | $174,604.01 | $179,895 |
| $204 | $161,758.01 | $166,515 | $215 | $170,826.01 | $175,851 | $226 | $179,895.01 | $185,186 |
| $213 | $166,515.01 | $171,273 | $224 | $175,851.01 | $180,875 | $236 | $185,186.01 | $190,477 |
| $222 | $171,273.01 | $176,030 | $234 | $180,875.01 | $185,899 | $246 | $190,477.01 | $195,768 |
| $231 | $176,030.01 | $180,788 | $244 | $185,899.01 | $190,923 | $257 | $195,768.01 | $201,059 |
| $240 | $180,788.01 | $185,545 | $254 | $190,923.01 | $195,948 | $267 | $201,059.01 | $206,350 |
| $250 | $185,545.01 | $190,303 | $264 | $195,948.01 | $200,972 | $278 | $206,350.01 | $211,641 |
| 200% FPIG | $161,960 | | 200% FPIG | $171,040 | | 200% FPIG | $180,120 |
| Weekly Co-pay | Family Size: 19 Annual Income | Weekly Co-pay | Family Size: 20 Annual Income | Weekly Co-pay | Family Size: 21 Annual Income |
| $5 | Less than: | $11,116 | $5 | Less than: | $11,649 | $5 | Less than: | $12,182 |
| $7 | $11,116.01 | $16,673 | $7 | $11,649.01 | $17,473 | $8 | $12,182.01 | $18,274 |
| $11 | $16,673.01 | $22,231 | $11 | $17,473.01 | $23,298 | $12 | $18,274.01 | $24,365 |
| $15 | $22,231.01 | $27,789 | $16 | $23,298.01 | $29,122 | $16 | $24,365.01 | $30,456 |
| $19 | $27,789.01 | $33,347 | $20 | $29,122.01 | $34,947 | $21 | $30,456.01 | $36,547 |
| $24 | $33,347.01 | $38,904 | $25 | $34,947.01 | $40,771 | $26 | $36,547.01 | $42,638 |
| $29 | $38,904.01 | $44,462 | $30 | $40,771.01 | $46,596 | $31 | $42,638.01 | $48,730 |
| $34 | $44,462.01 | $50,020 | $35 | $46,596.01 | $52,420 | $37 | $48,730.01 | $54,821 |
| $39 | $50,020.01 | $55,578 | $41 | $52,420.01 | $58,245 | $43 | $54,821.01 | $60,912 |
| $45 | $55,578.01 | $61,135 | $47 | $58,245.01 | $64,069 | $49 | $60,912.01 | $67,003 |
| $50 | $61,135.01 | $66,693 | $53 | $64,069.01 | $69,894 | $55 | $67,003.01 | $73,094 |
| $57 | $66,693.01 | $72,251 | $59 | $69,894.01 | $75,718 | $62 | $73,094.01 | $79,186 |
| $63 | $72,251.01 | $77,809 | $66 | $75,718.01 | $81,543 | $69 | $79,186.01 | $85,277 |
| $70 | $77,809.01 | $83,366 | $73 | $81,543.01 | $87,367 | $76 | $85,277.01 | $91,368 |
| $76 | $83,366.01 | $88,924 | $80 | $87,367.01 | $93,192 | $84 | $91,368.01 | $97,459 |
| $83 | $88,924.01 | $94,482 | $87 | $93,192.01 | $99,016 | $92 | $97,459.01 | $103,550 |
| $91 | $94,482.01 | $100,040 | $95 | $99,016.01 | $104,841 | $100 | $103,550.01 | $109,642 |
| $98 | $100,040.01 | $105,597 | $103 | $104,841.01 | $110,665 | $107 | $109,642.01 | $115,733 |
| $105 | $105,597.01 | $111,155 | $110 | $110,665.01 | $116,490 | $115 | $115,733.01 | $121,824 |
| $113 | $111,155.01 | $116,713 | $118 | $116,490.01 | $122,314 | $124 | $121,824.01 | $127,915 |
| $120 | $116,713.01 | $122,271 | $126 | $122,314.01 | $128,138 | $132 | $127,915.01 | $134,006 |
| $128 | $122,271.01 | $127,828 | $134 | $128,138.01 | $133,963 | $141 | $134,006.01 | $140,098 |
| $136 | $127,828.01 | $133,386 | $143 | $133,963.01 | $139,787 | $149 | $140,098.01 | $146,189 |
| $145 | $133,386.01 | $138,944 | $152 | $139,787.01 | $145,612 | $158 | $146,189.01 | $152,280 |
| $153 | $138,944.01 | $144,502 | $160 | $145,612.01 | $151,436 | $168 | $152,280.01 | $158,371 |
| $162 | $144,502.01 | $150,059 | $169 | $151,436.01 | $157,261 | $177 | $158,371.01 | $164,462 |
| $171 | $150,059.01 | $155,617 | $179 | $157,261.01 | $163,085 | $187 | $164,462.01 | $170,554 |
| $180 | $155,617.01 | $161,175 | $188 | $163,085.01 | $168,910 | $197 | $170,554.01 | $176,645 |
| $189 | $161,175.01 | $166,733 | $198 | $168,910.01 | $174,734 | $207 | $176,645.01 | $182,736 |
| $198 | $166,733.01 | $172,290 | $208 | $174,734.01 | $180,559 | $217 | $182,736.01 | $188,827 |
| $208 | $172,290.01 | $177,848 | $218 | $180,559.01 | $186,383 | $228 | $188,827.01 | $194,918 |
| $218 | $177,848.01 | $183,406 | $228 | $186,383.01 | $192,208 | $239 | $194,918.01 | $201,010 |
| $228 | $183,406.01 | $188,964 | $239 | $192,208.01 | $198,032 | $250 | $201,010.01 | $207,101 |
| $238 | $188,964.01 | $194,521 | $249 | $198,032.01 | $203,857 | $261 | $207,101.01 | $213,192 |
| $248 | $194,521.01 | $200,079 | $260 | $203,857.01 | $209,681 | $272 | $213,192.01 | $219,283 |
| $259 | $200,079.01 | $205,637 | $271 | $209,681.01 | $215,506 | $284 | $219,283.01 | $225,374 |
| $270 | $205,637.01 | $211,195 | $283 | $215,506.01 | $221,330 | $296 | $225,374.01 | $231,466 |
| $281 | $211,195.01 | $216,752 | $294 | $221,330.01 | $227,155 | $308 | $231,466.01 | $237,557 |
| $292 | $216,752.01 | $222,310 | $306 | $227,155.01 | $232,979 | $320 | $237,557.01 | $243,648 |
| 200% FPIG | $189,200 | | 200% FPIG | $198,280 | | 200% FPIG | $207,360 |
Pa. Code tit. 55, pt. V, subpt. B, ch. 3042, OVERPAYMENT AND DISQUALIFICATION, app B
Adopted by Pennsylvania Bulletin, Vol 53, No. 50. December 16, 2023, effective 12/16/2023