State of Wisconsin Department of Health Services

HISTORY

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

25-04 Version of 53.1 Copay Tables

53.1.1 Five Percent Copay Limit Tiers

2025 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

53.1.2 Fifty Percent Federal Poverty Level Limits

If the assistance group income is less than the applicable amount listed below, no copays are charged.

Assistance Group Size	Monthly Income
1	$652
2	$881
3	$1,110
4	$1,339
5	$1,568
6	$1,797

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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