| Family Size 2 | | Family Size 3 |
| Monthly Income | Monthly Co-Pay | | Monthly Income | Monthly Co-Pay |
| $0-1,763 | $1.00 | | $0-2,221 | $1.00 |
| 1,764 – 1,939 | 18.00 | | 2,222 – 2,443 | 22.00 |
| 1,940 – 2,115 | 39.00 | | 2,444 – 2,665 | 49.00 |
| 2,116 – 2,291 | 63.00 | | 2,666 – 2,887 | 80.00 |
| 2,292 – 2,468 | 92.00 | | 2,888 – 3,109 | 116.00 |
| 2,469 – 2,644 | 123.00 | | 3,110 – 3,331 | 156.00 |
| 2,645 – 2,820 | 159.00 | | 3,332 – 3,553 | 200.00 |
| 2,821 – 2,996 | 197.00 | | 3,554 – 3,775 | 249.00 |
| 2,997 – 3,173 | 210.00 | | 3,776 – 3,998 | 264.00 |
| 3,174 – 3,349 | 222.00 | | 3,999 – 4,220 | 280.00 |
| 3,350 – 3,525 | 235.00 | | 4,221 – 4,442 | 295.00 |
| 3,526 – 3,701 | 247.00 | | 4,443 – 4,664 | 311.00 |
| 3,702 – 3,878 | 259.00 | | 4,665 – 4,886 | 327.00 |
| 3,879 – 3,966 | 272.00 | | 4,887 – 4,997 | 342.00 |
| 3,967 – 4,054 | 278.00 | | 4,998 – 5,108 | 350.00 |
| 4,055 – 4,230 | 284.00 | | 5,109 – 5,330 | 358.00 |
| 4,231 – 4,406 | 296.00 | | 5,331 – 5,552 | 373.00 |
| 4,407 – 4,583 | 308.00 | | 5,553 – 5,774 | 389.00 |
| 4,584 – 4,759 | 321.00 | | 5,775 – 5,996 | 404.00 |
| 4,760 – 4,847 | 333.00 | | 5,997 – 6,107 | 420.00 |
| 4,848 – 5,883 | 330.00 | | 6,108 – 7,267 | 420.00 |
| Family Size 4 | | Family Size 5 |
| Monthly Income | Monthly Co-Pay | | Monthly Income | Monthly Co-Pay |
| $0-2,679 | $1.00 | | $0-3,138 | $1.00 |
| 2,680 – 2,947 | 27.00 | | 3,139 – 3,451 | 31.00 |
| 2,948 – 3,215 | 59.00 | | 3,452 – 3,765 | 69.00 |
| 3,216 – 3,483 | 96.00 | | 3,766 – 4,079 | 113.00 |
| 3,484 – 3,751 | 139.00 | | 4,080 – 4,393 | 163.00 |
| 3,752 – 4,019 | 188.00 | | 4,394 – 4,706 | 220.00 |
| 4,020 – 4,287 | 241.00 | | 4,707 – 5,020 | 282.00 |
| 4,288 – 4,555 | 300.00 | | 5,021 – 5,334 | 351.00 |
| 4,556 – 4,823 | 319.00 | | 5,335 – 5,648 | 373.00 |
| 4,824 – 5,090 | 338.00 | | 5,649 – 5,961 | 395.00 |
| 5,091 – 5,358 | 356.00 | | 5,962 – 6,275 | 417.00 |
| 5,359 – 5,626 | 375.00 | | 6,276 – 6,589 | 439.00 |
| 5,627 – 5,894 | 394.00 | | 6,590 – 6,903 | 461.00 |
| 5,895 – 6,028 | 413.00 | | 6,904 – 7,059 | 483.00 |
| 6,029 – 6,162 | 422.00 | | 7,060 – 7,216 | 494.00 |
| 6,163 – 6,430 | 431.00 | | 7,217 – 7,530 | 505.00 |
| 6,431 – 6,698 | 450.00 | | 7,531 – 7,844 | 527.00 |
| 6,699 – 6,966 | 469.00 | | 7,845 – 8,158 | 549.00 |
| 6,967 – 7,234 | 488.00 | | 8,159 – 8,471 | 571.00 |
| 7,235 – 7,368 | 506.00 | | 8,472 – 8,628 | 593.00 |
| 7,369 – 8,651 | 506.00 | | 8,629 – 10,036 | 593.00 |
| Family Size 6 | | Family Size 7 |
| Monthly Income | Monthly Co-Pay | | Monthly Income | Monthly Co-Pay |
| $0-3,596 | $1.00 | | $0-4,054 | $1.00 |
| 3,597 – 3,955 | 36.00 | | 4,055 – 4,460 | 41.00 |
| 3,956 – 4,315 | 79.00 | | 4,461 – 4,865 | 89.00 |
| 4,316 – 4,675 | 129.00 | | 4,866 – 5,270 | 146.00 |
| 4,676 – 5,034 | 187.00 | | 5,271 -5,676 | 211.00 |
| 5,035 – 5,394 | 252.00 | | 5,677 – 6,081 | 284.00 |
| 5,395 – 5,753 | 324.00 | | 6,082 – 6,487 | 365.00 |
| 5,754 – 6,113 | 403.00 | | 6,488 – 6,892 | 454.00 |
| 6,114 – 6,473 | 428.00 | | 6,893 – 7,298 | 483.00 |
| 6,474 – 6,832 | 453.00 | | 7,299 – 7,703 | 511.00 |
| 6,833 – 7,192 | 478.00 | | 7,704 – 8,108 | 539.00 |
| 7,193 – 7,551 | 504.00 | | 8,109 – 8,514 | 568.00 |
| 7,552 – 7,911 | 529.00 | | 8,515 – 8,919 | 596.00 |
| 7,912 – 8,091 | 554.00 | | 8,920 – 9,122 | 624.00 |
| 8,092 – 8,270 | 566.00 | | 9,123 – 9,325 | 639.00 |
| 8,271 – 8,630 | 579.00 | | 9,326 – 9,730 | 653.00 |
| 8,631 – 8,990 | 604.00 | | 9,731 – 10,135 | 681.00 |
| 8,991 – 9,349 | 629.00 | | 10,136 – 10,541 | 710.00 |
| 9,350 – 9,709 | 655.00 | | 10,542 – 10,946 | 738.00 |
| 9,710 – 9,889 | 680.00 | | 10,947 – 11,149 | 766.00 |
| 9,890 – 11,420 | 680.00 | | | |
| Family Size 8 | | Family Size 9 |
| Monthly Income | Monthly Co-Pay | | Monthly Income | Monthly Co-Pay |
| $0-4,513 | $1.00 | | $0-4,971 | $1.00 |
| 4,514 – 4,964 | 45.00 | | 4,972 – 5,468 | 50.00 |
| 4,965 – 5,415 | 99.00 | | 5,469 – 5,965 | 109.00 |
| 5,416 – 5,866 | 162.00 | | 5,966 – 6,462 | 179.00 |
| 5,867 – 6,318 | 235.00 | | 6,463 – 6,959 | 259.00 |
| 6,319 – 6,769 | 316.00 | | 6,960 – 7,456 | 348.00 |
| 6,770 – 7,220 | 406.00 | | 7,457 – 7,953 | 447.00 |
| 7,221 – 7,671 | 505.00 | | 7,954 – 8,450 | 557.00 |
| 7,672 – 8,123 | 537.00 | | 8,451 – 8,948 | 592.00 |
| 8,124 – 8,574 | 569.00 | | 8,949 – 9,445 | 626.00 |
| 8,575 – 9,025 | 600.00 | | 9,446 – 9,942 | 661.00 |
| 9,026 – 9,476 | 632.00 | | 9,943 – 10,439 | 696.00 |
| 9,477 – 9,928 | 663.00 | | 10,440 – 10,936 | 731.00 |
| 9,929 – 10,153 | 695.00 | | 10,937 – 11,184 | 766.00 |
| 10,154 – 10,379 | 711.00 | | 11,185 – 11,433 | 783.00 |
| 10,380 – 10,830 | 727.00 | | 11,434 – 11,930 | 800.00 |
| 10,831 – 11,281 | 758.00 | | | |
| 11,282 – 11,733 | 790.00 | | | |
| Family Size 10 |
| Monthly Income | Monthly Co-Pay |
| $0-5,429 | $1.00 |
| 5,430 – 5,972 | 54.00 |
| 5,973 – 6,515 | 119.00 |
| 6,516 – 7,058 | 195.00 |
| 7,059 – 7,601 | 282.00 |
| 7,602 – 8,144 | 380.00 |
| 8,145 – 8,687 | 489.00 |
| 8,688 – 9,230 | 608.00 |
| 9,231 – 9,773 | 646.00 |
| 9,774 – 10,315 | 684.00 |
| 10,316 – 10,858 | 722.00 |
| 10,859 – 11,401 | 760.00 |
| 11,402 – 11,944 | 798.00 |
(Source: Amended at 49 Ill. Reg. 15616, effective November 24, 2025)