EPIC
FEE SCHEDULE
|
|
DEDUCTIBLE SCHEDULE
SINGLE
Annual Income |
Deductible |
Under $20,000 |
Not Available |
$20,001 - $21,000 |
$ 530 |
$21,001 - $22,000 |
550 |
$22,001 - $23,000 |
580 |
$23,001 - $24,000 |
720 |
$24,001 - $25,000 |
750 |
$25,001 - $26,000 |
780 |
$26,001 - $27,000 |
810 |
$27,001 - $28,000 |
840 |
$28,001 - $29,000 |
870 |
$29,001 - $30,000 |
900 |
$30,001 - $31,000 |
930 |
$31,001 - $32,000 |
960 |
$32,001 - $33,000 |
1,160 |
$33,001 - $34,000 |
1,190 |
$34,001 - $35,000 |
1,230 |
Over $35,000 |
Not Eligible |
MARRIED
Joint Annual Income |
Deductible |
Under $26,000 |
Not Available |
$26,001 - $27,000 |
$ 650 |
$27,001 - $28,000 |
675 |
$28,001 - $29,000 |
700 |
$29,001 - $30,000 |
725 |
$30,001 - $31,000 |
900 |
$31,001 - $32,000 |
930 |
$32,001 - $33,000 |
960 |
$33,001 - $34,000 |
990 |
$34,001 - $35,000 |
1,020 |
$35,001 - $36,000 |
1,050 |
$36,001 - $37,000 |
1,080 |
$37,001 - $38,000 |
1,110 |
$38,001 - $39,000 |
1,140 |
$39,001 - $40,000 |
1,170 |
$40,001 - $41,000 |
1,200 |
$41,001 - $42,000 |
1,230 |
$42,001 - $43,000 |
1,260 |
$43,001 - $44,000 |
1,290 |
$44,001 - $45,000 |
1,320 |
$45,001 - $46,000 |
1,575 |
$46,001 - $47,000 |
1,610 |
$47,001 - $48,000 |
1,645 |
$48,001 - $49,000 |
1,680 |
$49,001 - $50,000 |
1,715 |
Over $50,000 |
Not Eligible |
For Each Prescription Costing: | Enrollees Pay: |
---|---|
Up to $ 15 | $ 3 |
$ 15.01 to $ 35 | $ 7 |
$ 35.01 to $ 55 | $ 15 |
Over $ 55 | $ 20 |