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.