Patient Assistance Eligibility Guidelines

Effective January 24, 2013

Family Size atMonthly Income
up to 175%
Monthly Income
from 175% to 225%
Monthly Income
from 225% to 250%
Monthly Income
Over 250%
11,6762,1542,3942,394
22,2622,9083,2313,231
32,8483,6624,0694,069
43,4344,4164,9064,906
54,0215,1695,7445,744
64,6075,9236,5816,581
75,1936,6777,4197,419
85,7797,4318,2568,256
over 8 add for each:586754921921
Amount of Assistance100%50%15%0%
Family Size atAnnual Income
up to 175%
Annual Income
from 175% to 225%
Annual Income
from 225% to 250%
Annual Income
Over 250%
120,10825,85328,72527,726
227,14334,89837,77537,776
334,17842,94348,82548,286
441,21352,98858,87558,876
548,24862,03368,92568,926
655,28371,07878,97578,976
762,31880,12389,02589,026
869,35389,16899,07599,076
over 8 add for each:7,0359,04511,05511,056
Amount of Assistance100%50%15%0%

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