How to use this chart:
Step 1: Locate the number of people in your household.
Step 2: Find the box that matches your household's annual gross income and age of your children.
Step 3: Look down the row to the COST BOX to see your appropriate average monthly cost per child and the co-payments per child, per visit.
Example: A four-person household with an annual income of $69,840 will have an average monthly premium of $74 per child, plus any co-pays for services.