For clients without insurance coverage and those choosing confidential services, WUPHD offers Family planning and STD program on a sliding fee scale. Use your income and family size to determine contribution level.
| Family Size | Income range for 0% contribution | Income range for 25% contribution | Income range for 50% contribution | Income range for 75% contribution | Income limit for 100% contribution | ||||
| 1 | 0-- | 12,880 | 12,881 | 19,320 | 19,321 | 25,760 | 25,761 | 32,200 | 32,201 |
| 2 | 0-- | 17,420 | 17,421 | 26,130 | 26,131 | 34,840 | 34,841 | 43,550 | 43,551 |
| 3 | 0-- | 21,960 | 21,961 | 32,940 | 32,941 | 43,920 | 43,921 | 54,900 | 54,901 |
| 4 | 0-- | 26,500 | 26,501 | 39,750 | 39,751 | 53,000 | 53,001 | 66,250 | 66,251 |
| 5 | 0-- | 31,040 | 31,041 | 46,560 | 46,561 | 62,080 | 62,081 | 77,600 | 77,601 |
| 6 | 0-- | 35,580 | 35,581 | 53,370 | 53,371 | 71,160 | 71,161 | 88,950 | 88,951 |
| 7 | 0-- | 40,120 | 40,121 | 60,180 | 60,181 | 80,240 | 80,241 | 100,300 | 100,301 |
| 8 | 0-- | 44,660 | 44,661 | 66,990 | 66,991 | 89,320 | 89,321 | 111,650 | 111,651 |
| Each additional family member | $4,540 | $6,810 | $9,080 | $11,350 | $11,351 | ||||
| % to charge | 0%/Donation | 25% | 50% | 75% | 100% |
Once you’ve calculated your contribution level, the fee schedule below will help you calculate the cost of services at the health department.
| Service Type | Donation | 25% | 50% | 75% | 100% |
|---|---|---|---|---|---|
| Contraceptive Implant Insertion | $0.00 | $18.25 | $36.50 | $54.75 | $73.00 |
| Contraceptive Implant Removal | $0.00 | $18.25 | $36.50 | $54.75 | $73.00 |
| Diaphragm Fit Visit | $0.00 | $25.00 | $50.00 | $75.00 | $100.00 |
| IUD Insertion | $0.00 | $17.50 | $35.00 | $52.50 | $70.00 |
| IUD Removal | $0.00 | $13.25 | $26.50 | $39.75 | $53.00 |
| NP Visit, New Pt, (Expanded Problem Focused/Low to Moderate) | $0.00 | $20.00 | $40.00 | $60.00 | $80.00 |
| NP Visit, New Pt, (Detailed Problem Focused/Moderate) | $0.00 | $25.00 | $50.00 | $75.00 | $100.00 |
| RN Visit | $0.00 | $7.50 | $15.00 | $22.50 | $30.00 |
| Supplies Only Visit or Treatment Visit (including EPT) | NC | NC | NC | NC | NC |
| IUD Follow-up Visit | $0.00 | $7.50 | $15.00 | $22.50 | $30.00 |
| NP Visit, Est Pt, (Expanded Problem Focused/Low to Moderate) | $0.00 | $15.00 | $30.00 | $45.00 | $60.00 |
| NP Visit, Est Pt, (Detailed Problem Focused/Moderate) | $0.00 | $20.00 | $40.00 | $60.00 | $80.00 |
| Preventive Visit, New Pt 12-17y | $0.00 | $51.25 | $102.50 | $153.75 | $205.00 |
| Preventive Visit, New Pt 18-39y | $0.00 | $51.25 | $102.50 | $153.75 | $205.00 |
| Preventive Visit, New Pt 40-64y | $0.00 | $60.00 | $120.00 | $180.00 | $240.00 |
| Preventive Visit, Est Pt, 12-17y | $0.00 | $48.75 | $97.50 | $146.25 | $195.00 |
| Preventive Visit, Est Pt, 18-39y | $0.00 | $48.75 | $97.50 | $146.25 | $195.00 |
| Preventive Visit, Est Pt, 40-64y | $0.00 | $48.75 | $97.50 | $146.25 | $195.00 |
| Lab/Procedure | |||||
| Pap Test (obtaining specimen for screening) | NC | NC | NC | NC | NC |
| Venipuncture | $0.00 | $7.50 | $15.00 | $22.50 | $30.00 |
| Destruction of lesions, male | $0.00 | $7.50 | $15.00 | $22.50 | $30.00 |
| Destruction of lesions, female | $0.00 | $7.50 | $15.00 | $22.50 | $30.00 |
| Urinalysis Dipstick | $0.00 | $2.50 | $5.00 | $7.50 | $10.00 |
| Pregnancy Test Urine | $0.00 | $3.00 | $6.00 | $9.00 | $12.00 |
| Hemoglobin | $0.00 | $2.50 | $5.00 | $7.50 | $10.00 |
| Syphilis Panel (sent to State Lab) | NC | NC | NC | NC | NC |
| HIV Test (Rapid) | NC | NC | NC | NC | NC |
| Hep C Test | NC | NC | NC | NC | NC |
| Wet Prep | $0.00 | 3.00 | 6.00 | 9.00 | 12.00 |
| Herpes Simplex Virus PCR | $0.00 | 25.00 | 50.00 | 75.00 | 100.00 |
| Trichomonas Amp | $0.00 | $3.00 | $6.00 | $9.00 | $12.00 |
| Injection Administration | $0.00 | $7.50 | $15.00 | $22.50 | $30.00 |
| Chlamydia & Gonorrhea Lab Test | $0.00 | $14.53 | $29.05 | $43.58 | $58.10 |
| HPV Testing (added to pap test) | $0.00 | $12.50 | $25.00 | $37.50 | $50.00 |
| HBV (Hep B) Test | NC | NC | NC | NC | NC |
| Contraceptive Supplies | |||||
| Condoms, 1 doz. | NC | NC | NC | NC | NC |
| Diaphragm 1 unit | $0.00 | $10.00 | $20.00 | $30.00 | $40.00 |
| Jelly, Cream or Foam | $0.00 | $2.50 | $5.00 | $7.50 | $10.00 |
| Depo Provera | $0.00 | $12.00 | $24.00 | $36.00 | $48.00 |
| Emergency Contraceptive (Plan B) | $0.00 | $6.25 | $12.50 | $18.75 | $25.00 |
| Intrauterine Device (Paragard, Mirena, Kyleena) | Based on Cost of device | ||||
| Nexplanon | $0.00 | $99.75 | $199.50 | $299.25 | $399.00 |
| Nuvaring | $0.00 | $10.00 | $20.00 | $30.00 | $40.00 |
| Oral Contraceptives (per package) | $0.00 | $3.00 | $6.00 | $9.00 | $12.00 |
| Pharmaceutical Supplies | |||||
| Hep B Vaccine (if MIAVP eligible) | NC | NC | NC | NC | NC |
| Rocephin Injection | NC | NC | NC | NC | NC |
| Fluconazole 150 mg #1 | NC | NC | NC | NC | NC |
| Acyclovir 400 mg | $0.00 | $2.50 | $5.00 | $7.50 | $10.00 |
| Amoxicillin 500 mg | $0.00 | $3.75 | $7.50 | $11.25 | $15.00 |
| Bactrim DS | $0.00 | $3.75 | $7.50 | $11.25 | $15.00 |
| Penicillin G Injection | NC | NC | NC | NC | NC |
| Cefixime 400 mg | NC | NC | NC | NC | NC |
| Clindamycin 150 mg | NC | NC | NC | NC | NC |
| Doxycycline 100 mg | NC | NC | NC | NC | NC |
| Metronidazole #4 | NC | NC | NC | NC | NC |
| Metronidazole #14 | NC | NC | NC | NC | NC |
| Metronidazole Gel 0.75% 70gm Tube | $0.00 | $5.00 | $10.00 | $15.00 | $20.00 |
| Zithromax 1 gm | NC | NC | NC | NC | NC |