Drug Benefit List 2012

32:00 CONTRACEPTIVES (NON-ORAL)

32:00.00 CONTRACEPTIVES (NON-ORAL)

CONDOM, MALE

Device

99400527 CONDOM, LATEX, LUBRICATED

99400485 CONDOM, LATEX, LUBRICATED, NONOXYNOL

99400486 CONDOM, LATEX, NON- LUBRICATED

99400786 CONDOM, NON-LATEX, LUBRICATED

INTRAUTERINE DEVICE

Limited use benefit with quantity and frequency limits (prior approval is not required).

Coverage is granted for 1 device every 30 months.

Device

98099999 FLEXI-T IUD TSN

99400482 NOVA-T IUD BEX