Patient Assistance Eligibility Guidelines
Effective January 24, 2013
| Family Size at | Monthly Income up to 175% | Monthly Income from 175% to 225% | Monthly Income from 225% to 250% | Monthly Income Over 250% |
| 1 | 1,676 | 2,154 | 2,394 | 2,394 |
| 2 | 2,262 | 2,908 | 3,231 | 3,231 |
| 3 | 2,848 | 3,662 | 4,069 | 4,069 |
| 4 | 3,434 | 4,416 | 4,906 | 4,906 |
| 5 | 4,021 | 5,169 | 5,744 | 5,744 |
| 6 | 4,607 | 5,923 | 6,581 | 6,581 |
| 7 | 5,193 | 6,677 | 7,419 | 7,419 |
| 8 | 5,779 | 7,431 | 8,256 | 8,256 |
| over 8 add for each: | 586 | 754 | 921 | 921 |
| Amount of Assistance | 100% | 50% | 15% | 0% |
| Family Size at | Annual Income up to 175% | Annual Income from 175% to 225% | Annual Income from 225% to 250% | Annual Income Over 250% |
| 1 | 20,108 | 25,853 | 28,725 | 27,726 |
| 2 | 27,143 | 34,898 | 37,775 | 37,776 |
| 3 | 34,178 | 42,943 | 48,825 | 48,286 |
| 4 | 41,213 | 52,988 | 58,875 | 58,876 |
| 5 | 48,248 | 62,033 | 68,925 | 68,926 |
| 6 | 55,283 | 71,078 | 78,975 | 78,976 |
| 7 | 62,318 | 80,123 | 89,025 | 89,026 |
| 8 | 69,353 | 89,168 | 99,075 | 99,076 |
| over 8 add for each: | 7,035 | 9,045 | 11,055 | 11,056 |
| Amount of Assistance | 100% | 50% | 15% | 0% |
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