Fertility services and fertility solutions (FS) program
Therapeutic services for the fertility treatment when provided by or under the direction of a physician. Benefits are limited to the following procedures:
- Assisted Reproductive Technologies (ART), including but not limited to InVitro fertilization (IVF). ART procedures include, but are not limited to:
- Egg/oocyte retrieval.
- Fresh or frozen embryo transfer.
- Intracytoplasmic sperm injection - ICSI.
- Assisted hatching.
- Cryopreservation and storage of embryos for 12 months.
- Embryo biopsy for PGT-M or PGT-SR (formerly known as PGD).
- Frozen Embryo Transfer cycle including the associated cryopreservation and storage of embryos.
- Insemination procedures (artificial insemination (AI) and intrauterine insemination (IUI)).
- Ovulation induction (or controlled ovarian stimulation).
- Testicular Sperm Aspiration/Microsurgical Epididymal Sperm Aspiration (TESA/MESA) - male factor associated surgical procedures for retrieval of sperm.
- Surgical Procedures, including but not limited to: Laparoscopy, Lysis of adhesions, tubotubal anastomosis, fimbrioplasty, salpingostomy, resection and ablation of endometriosis, transcervical tubal catheterization, and ovarian cystoplasty.
- Pre-implantation Genetic Testing for a Monogenic Disorder (PGT-M) or Structural Rearrangement (PGT-SR) - when the genetic parents carry a gene mutation to determine whether that mutation has been transmitted to the embryo."
Treatment for the diagnosis and treatment of the underlying cause of infertility is covered as described in the SPD. Benefits for diagnostic tests are covered as under Scopic Procedures - Outpatient Diagnostic and Therapeutic, Office Visits.
Benefits for certain pharmaceutical products, including specialty pharmaceutical products, for the treatment of infertility that are administered on an outpatient basis in a hospital, alternate facility, physician's office, or in your home are covered under injectable drugs.
Benefits for pharmaceutical products for outpatient use that are filled by a prescription order or refill are described under the Prescription Drugs section.
Embryo biopsy for Pre-implantation Genetic Screening (PGS) used to select embryos for transfer in order to increase the chance for conception.
Donor coverage --The plan will cover associated donor medical expenses, including collection and preparation of ovum and/or sperm, and the medications associated with the collection and preparation of ovum and/or sperm. The Plan will not pay for donor charges associated with compensation or administrative services.
Fertility preservation for medical reasons - when planned cancer or other medical treatment is likely to produce Infertility/sterility. Coverage is limited to: collection of sperm, cryopreservation of sperm, ovarian stimulation and retrieval of eggs, oocyte cryopreservation, InVitro fertilization, and embryo cryopreservation. Long-term storage costs (anything longer than 12 months) are not covered.
Fertility preservation for non-medical reasons - when you would like to delay Pregnancy for non-medical reasons. Coverage is limited to: collection of sperm, cryopreservation of sperm, ovarian stimulation and retrieval of eggs, oocyte cryopreservation, in vitro fertilization, and embryo cryopreservation. Long-term storage costs (anything longer than 12 months) are not covered.
To be eligible for the fertility services benefit:
- You are a female:
Note. For treatment initiated prior to pertinent birthday, services will be covered to completion of initiated cycle.
- Child Dependents are eligible for Infertility benefit if above eligibility criteria are met. Child Dependents are eligible for fertility preservation when planned cancer or other medical treatment is likely to produce infertility/sterility.
Certain criteria to be eligible for Benefits may be waived for Fertility Preservation for medical or non-medical reasons.
Any combination of in-network benefits and out-of-network benefits are limited to $25,000 for medical services and $10,000 for prescription drugs per covered person during the entire period of time he or she is enrolled for coverage under the Plan. This limit does not include physician office visits for the treatment of infertility.
There are separate limits under the Plan for medical services and prescription drugs.
Charges for the following apply toward the fertility lifetime maximum:
You must enroll in the Fertility Solutions Program to receive services from a designated provider. To enroll you can call the telephone number on your ID card or you can call the Fertility Solutions Program Nurse Team at 888-936-7246.
The Plan pays benefits for the fertility services described above when provided by designated providers participating in the Fertility Solutions (FS) program. The Fertility Solutions (FS) provides education, counseling, fertility management and access to a national network of premier fertility treatment clinics.
Covered members who do not live within a 60 mile radius of a FS designated provider will need to contact an FS case manager to determine a network facility prior to starting treatment. For fertility services and supplies to be considered covered health services, contact FS and enroll with a nurse consultant prior to receiving services.