CMSP Premium and Copayment Chart
Monthly Premiums
 
Family Size		0-199.9% FPL		200.0 - 300.9% FPL
see FPL chart		  $0			  $7.80 per child/max.$23.40 per family

		301.0-400.0% FPL 			400.1% and above FPL 
		$33.14 per family 			$64.00 per child

Copayments*			0-199.9% FPL		200.0 - 300.9% FPL 
Medical (non-
preventive)			$2				$5
Dental 				$2				$4

				301.0-400.0% FPL 		400.1% and above FPL 
Medical (non-
preventive)			$5				$8
Dental				$4				$6

Pharmacy (for all FPL groups)
$3 for each generic drug, $4 for each brand name drug


*Only one copayment is required per day for medical visits.

This chart is provided as a guide only, as more factors are 
included in final income calculations.