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.