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.