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 United States (US) 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.