Plan First! Rev: 06/25/2015 Family Planning Waiver Program Covered Services January 2015

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1 The Plan First! () is a limited services benefit plan which covers office visits, routine laboratory, diagnostic tests and surgical procedures associated with family planning. Initial treatment for Sexually Transmitted Infections (STI) is covered when provided in conjunction with other family planning services. The Plan First! will cover all pharmaceuticals within the therapeutic drug classes appearing in Table 6 as they relate to family planning, initial treatment of STIs and sterilization services. This document provides a current list of covered services codes for Plan First! The Current Procedural Terminology (CPT) codes listed below in Tables 1-4 will only be covered when accompanied by one of the ICD-9-CM diagnosis codes identified in Table 5 on the claim form. For more information regarding this program, refer to the PLAN FIRST! Family Planning Waiver Chapter located in the Michigan Medicaid Provider Manual via the MDCH website. To access this information, click hyperlink: Covered s Table 1 Evaluation and Management (Office Visit) Codes Codes are covered only if they are provided for a family planning visit Office/Outpatient Visit New Office/Outpatient Visit New Office/Outpatient Visit New Office/Outpatient Visit Est Office/Outpatient Visit Est Office/Outpatient Visit Est Prev Visit New Age Prev Visit New Age Prev Visit Est Age Prev Visit Est Age G0463 Hospital Outpt Clinic Visit Table Removal of Contraceptive Cap Insert Drug Implant Device Remove Drug Implant Device Remove/Insert Drug Implant Fitting Of Diaphragm/Cap Page 1 of 5

2 58300 Insert Intrauterine Device Remove Intrauterine Device Catheter for Hysterography X-ray Female Genital Tract Metabolic Panel Total Ca Comprehen Metabolic Panel Hepatic Function Panel Urinalysis Nonauto W/Scope Urinalysis Auto W/Scope Urinalysis Nonauto W/O Scope Urinalysis Auto W/O Scope Microscopic Exam Of Urine Urine Pregnancy Test Assay Bld/Serum Cholesterol Assay Glucose Blood Quant Reagent Strip/Blood Glucose Chorionic Gonadotropin Assay Spun Microhematocrit Hematocrit Hemoglobin Rbc Sickle Cell Test Syphilis Test Non-Trep Qual Htlv/Hiv Confirmatory Test Hiv Hiv Hiv-1/Hiv-2 Single Assay Treponema Pallidum Culture Bacteria Other Culture Bacteria Except Blood Culture Aerobic Identify Culture Screen Only Culture Chlamydia Smear Gram Stain Smear Special Stain Smear Wet Mount Saline/Ink Chlamydia Trachomatis Ag If Herpes Simplex 2 Ag If Herpes Simplex 1 Ag If Page 2 of 5

3 87340 Hepatitis B Surface Ag Eia Chylmd Trach Ag Eia Candida Dna Dir Probe Chylmd Trach Dna Dir Probe Chylmd Trach Dna Amp Probe Hsv Dna Dir Probe N.Gonorrhoeae Dna Dir Prob N.Gonorrhoeae Dna Amp Prob Cytopath C/V Interpret Cytopath C/V Thin Layer Cytopath C/V Thin Layer Redo Cytopath C/V Automated Cytopath C/V Auto Rescreen Cytopath C/V Index Add-On Cytopath Tbs C/V Manual Cytopath Tbs C/V Redo Cytopath Tbs C/V Auto Redo Cytopath Tbs C/V Select Cytopath C/V Auto In Fluid Cytopath C/V Auto Fluid Redo Ther/Proph/Diag Inj Sc/Im Table 3 Contraceptive Supply Codes HCPCS Code A4264 A4266 A4267 A4268 A4269 J0696 J1050 J7300 J7301 J7302 J7303 Intratubal Occlusion Device Diaphragm Male Condom Female Condom Spermicide Ceftriaxone Sodium Injection Medroxyprogesterone Acetate Intraut Copper Contraceptive Skyla 13.5 MG Levonorgestrel Iu Contracept Contraceptive Vaginal Ring Page 3 of 5

4 Contraceptive Supply Codes HCPCS Code J7304 J7307 Q0144 S4989 S4993 Contraceptive Hormone Patch Etonogesterel Implant System Azithromycin Dihydrate, Oral Contracept Iud Contraceptive Pill For Bc Table 4 Sterilization Procedure Codes Anesth Surg Lower Abdomen Anesth Tubal Ligation Anesth Hysteroscope/Graph Hysteroscopy Sterlizaion Division of Fallopian Tube Occlude Fallopian Tube(s) Laparoscopy Tubal Cautery Laparoscopy Tubal Block ICD-9-CM Codes Table 5 ICD-9-CM Diagnosis Codes ICD-9-CM Code V25.01 Prescrip-Oral Contracept V25.02 Initiate Contracept Nec V25.03 Contracept Mgmt-Emergncy V25.04 Natrl Fam Pln-Avoid Preg V25.09 Contraceptive Mangmt Nec V25.11 Insertion Of IUD V25.12 Removal Of IUD V25.13 Remove/Insert IUD V25.2 Sterilization V25.3 Menstrual Extraction V25.40 Contracept Surveill Nos V25.41 Contracept Pill Surveill Page 4 of 5

5 ICD-9-CM Diagnosis Codes ICD-9-CM Code V25.42 Iud Surveillance V25.43 Srvl Mplnt Sbdrm Cntrcep V25.49 Contracept Surveill Nec V25.5 Nsrt Mplnt Sbdrm Cntrcep V25.8 Contraceptive Mangmt Nec V25.9 Contraceptive Mangmt Nos Pharmaceuticals This program will cover antiviral medications for the initial treatment of a STI, which is limited to general antiviral and topical antiviral medications. This does not include pharmaceuticals for the treatment of Hepatitis B, Hepatitis C, or HIV. Contraceptives, Non-systemic Systemic Contraceptives Tetracyclines Penicillins Erythromycins Streptomycins Table 6 Drug Therapeutic Class Cephalosporins Trimethoprim Antivirals Narcotic Analgesics (for sterilization surgical procedures) Non-Narcotic Analgesics (for sterilization surgical procedures) Antifungals Flagyl Page 5 of 5