1.0 POLICY
The family planning procedures listed below
may be cost-shared:
1.1 Surgical insertion, removal,
and replacement of intrauterine devices.
1.2 Measurement for, and purchase
of, contraceptive diaphragms, including remeasurement and replacement.
1.3 Prescription
contraceptives and prescription contraceptives used as emergency
contraceptives.
Note: Implantable prescription contraceptives
are covered if the U.S. Food and Drug Administration (FDA) approved
and used for the labeled indication.
1.4 Male and
female surgical sterilization.
2.0 EXCLUSIONS
2.1 Prophylactics
(condoms).
2.2 Spermicidal foams, jellies, and sprays not
requiring a prescription.
2.3 Services and supplies related
to noncoital reproductive technologies, including but not limited to
artificial insemination (including cost related to donors and semen
banks), In Vitro Fertilization (IVF) and Gamete Intrafallopian Transfer
(GIFT).
2.4 Male and female reversal of a surgical sterilization
procedure
, except medically necessary reversal of
surgical sterilization for the treatment of a disease or injury
(see Chapter 4, Sections 15.1 and 17.1).
2.5 For routine
screening Papanicolaou (PAP) smear tests, routine gynelogic examinations,
and related laboratory testing, see the Preventive Services policy.
2.6 The family
planning benefit does not include screening PAP smear tests, routine
gynelogic examinations, including related laboratory testing. However,
family planning benefits may be allowed during an office visit for
a screening PAP test.