Criteria
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the
www.fepblue.org
website.
When contraceptive management services are provided solely for contraceptive purposes, eligibility is determined according to specific individual or group customer benefits.
When provided for treatment of medical conditions, and not solely for contraceptive purposes, contraceptive devices, implants, medications, injections and related services may be considered medically necessary, including but not limited to:
- Acne
-
Amenorrhea
- Androgen excess
-
Bleeding
- Abnormal uterine and vaginal bleeding
- Due to Fibroids or Polyps
- Excessive bleeding in the premenopausal period
- Ovulation bleeding
- Post-menopausal
- Conditions requiring withdrawal bleeding
- Corpus luteum cyst of ovary
-
Dysmenorrhea
- Endometrial cancer prevention
- Endometriosis in cutaneous scar
-
Endometriosis of:
- Fallopian Tube
- Intestine
- Ovary
- Pelvic peritoneum
- Rectovaginal septum and vagina
- Uterus
- Follicular cyst of ovary
- Hematocolpos
- Hirsutism
- Hyperlactation
-
Menstruation
- Excessive and frequent menstruation with irregular cycle
- Excessive and frequent menstruation with regular cycle
- Excessive menstruation at puberty
- Irregular menstruation
- Menstrual Migraine
-
Oligomenorrhea
- Ovarian cancer prevention
-
Ovarian conditions
- Hyper-stimulation of ovaries
- Ovarian dysfunction
- Ovarian cyst
- Polycystic ovarian syndrome
- Primary ovarian failure
- Pituitary gland disorders
-
Post-procedural ovarian failure
-
Premature menopause
- Premenstrual dysphoric disorder
- Premenstrual tension syndrome
- The individual requires therapy with a contraceptive in conjunction with a drug that is contraindicated in pregnancy in FDA labeling.
When a contraceptive device, implant, medication, injection, or related service is provided for medical conditions other than those listed above, it is considered a non-covered service.
Procedure Codes
11976 | 11981 | 11982 | 11983 | 57170 | 58300 | 58301 |
A4261 | A4266 | J1050 | J7294 | J7295 | J7296 | J7297 |
| J7298 | J7300 | J7301 | J7304 | J7306 | J7307 | S4981 |
S4989 | S4993 |
