State of Wisconsin
Department of Health Services

HISTORY

The policy on this page is from a previous version of the handbook. 

20-03 Version of 53.1 Five Percent Copay Limit Tiers

2020 Per-Member Copay Limits

Status

Assistance Group Income Tier as Percentage of the Federal Poverty Level

0-50%

>50-100%

>100-150%

>150-200%

>200-250%

>250-300%

>300-350%

>350-400%

>400-450%

>450-500%

>500%

Individual

$0

$26

$53

$79

$106

$132

$159

$186

$212

$239

$265

Prorated (split between counted spouses)

$0

$13

$26.50

$39.50

$53

$66

$79.50

$93

$106

$119.50

$132.50

This page last updated in Release Number: 20-03
Release Date: 08/03/2020
Effective Date: 07/01/2020


The information concerning the BadgerCare Plus program provided in this handbook release is published in accordance with: Titles XI, XIX and XXI of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapter 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2 and 101 through 109 of the Wisconsin Administrative Code.

Publication Number: P-10171