Comprehensive Infertility Services. Infertility services and supplies to diagnose the underlying medical cause of Infertility are covered. Coverage is provided for the following outpatient services and supplies: • In-vitro fertilization; • Uterine embryo lavage; • Embryo transfer; • Artificial Insemination; • Gamete intrafallopian tube transfer; • Zygote intrafallopian tube transfer; and • Low tubal ovum transfer. Limitations Covered Benefits will only include charges for procedures for in vitro fertilization, gamete intrafallopian tube transfers and zygote intrafallopian tube transfer if: • The Member has been unable to attain or sustain a successful pregnancy through reasonable, less costly medically appropriate Infertility treatments for which coverage is available under this Certificate. • The Member has not undergone 4 completed oocyte retrievals, except that if a live birth follows a completed oocyte retrieval, then 2 more completed oocyte retrievals shall be covered. • The procedures are performed at medical facilities that conform to the American College of Obstetric and Gynecology guidelines for in vitro fertilization clinics or to the American Fertility Society minimal standards for programs of in vitro fertilization.
Comprehensive Infertility Services. Infertility services and supplies to diagnose the underlying medical cause of Infertility are covered. Coverage is provided for the following outpatient services and supplies: • In-vitro fertilization (IVF); • Uterine embryo lavage; • Embryo transfer; • Artificial Insemination; • Gamete intrafallopian tube transfer (GIFT); • Zygote intrafallopian tube transfer (ZIFT); and • Low tubal ovum transfer. • Intracytoplasmic sperm injection (ICSI). Covered Benefits also include the medical expenses of a known Donor for egg or sperm retrieval and the procedure used to transfer the eggs or sperm to the Member. If an egg Donor is used, the completed egg retrieval performed on the Donor will count against the Member as one completed egg retrieval for the purposes of the lifetime maximum. If the Member is a female without a male partner attempting to become pregnant, Artificial Insemination is a Covered Benefit if the Member has had at least 12 cycles of Donor insemination (6 cycles for Members age 35 or older) prior to enrolling in HMO’s Infertility program. One completed egg retrieval could result in many IVF, GIFT, ZIFT, or ICSI procedures. There is no limit on the number of procedures, including less invasive procedures such as Artificial Insemination, until the final covered egg retrieval is completed. Limitations Covered Benefits will only include charges for the diagnosis and treatment of infertility, including prescription drug therapy, if the following tests are met: • The Member has been unable to attain or sustain a successful pregnancy through reasonable, less costly medically appropriate Infertility treatments for which coverage is available under this Certificate. In the event that the Member or partner has a medical condition that renders such treatment useless, this requirement shall be waived. • The Member has not undergone 4 completed egg retrievals, except that if a live birth follows a completed egg retrieval, then 2 more completed egg retrievals shall be covered. This applies to the Member per lifetime of that Member, for the treatment of Infertility, regardless of the source of payment. Once the final covered egg retrieval is completed, only 1 subsequent procedure used to transfer the egg or sperm to the covered recipient shall be covered. • The procedures are performed at medical facilities that conform to the American College of Obstetric and Gynecology guidelines for in vitro fertilization clinics or to the American Fertility Society minimal st...
