2016 San Mateo County Infertility Coverage
As a licensed Health Care Service Plan, we are required to issue a Group Agreement that is filed with and approved by the California
Department of Managed Health Care. Because our regulators expect that document to represent the agreement between Health Plan
and a group or an individual, we cannot allow a different document to supersede it. Under law, our Group Agreement is binding.
Coverage of Infertility benefits
Supplemental Infertility Coverage:
Covered for diagnosis and treatment of infertility when approved by a Plan physician.
Services covered are medically necessary diagnostic planning services for infertility
problems – provider visit, diagnosis, and treatment (Inpatient and Outpatient fertility
procedures, Infertility Treatment). Artificial insemination is covered except for donor
semen or donor eggs, donor ovum and services related to their procurement and storage.
All other services related to conception by artificial means are not covered.
Supplemental Assisted Reproductive Technology (ART):
Covered for gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), in
vitro fertilization (IVF), or cryopreserved embryo transfer. Coverage must be purchased in
addition to the supplemental infertility (artificial insemination “AI”/intrauterine “IUI”)
benefit.
Lifetime Maximum
Supplemental Infertility Coverage:
Supplemental Assisted Reproductive Technology (ART):
This benefit covers a single treatment cycle from one of the ART procedures (gamete
intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), in vitro fertilization
(IVF), or cryopreserved embryo transfer).
Infertility Treatments Covered
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Evaluation by a Specialist: YES (Infertility doctors are inherently specialists)
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Drug Therapy:
YES (as part of an approved treatment)
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In Vivo Fertilization:
YES
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In Vitro Fertilization:
YES (Supplemental ART)
Supplemental Infertility Coverage:
In Vivo Fertilization
A Plan physician determines if a member is fertile and also decides on the appropriate
course of treatment. Fertilization still takes place in the fallopian tube even though the
sperm are put in the uterus.
In Vitro Fertilization
Supplemental Assisted Reproductive Technology (ART):
A Plan physician determines fertility as well as the appropriate number of drug-induced
ovulation treatments a member would be given, prior to an ART procedure. In Vitro
fertilization is covered.
Infertility Questions (general)
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Diagnosis of Infertility covered: YES
Copay: Outpatient: 50% copay per visit; Inpatient: 50% copay per admission
Treatment of the underlying condition covered: YES
Copay: Outpatient: 50% copay per visit/surgical procedure; Inpatient: 50% copay per
admission
Artificial Insemination covered: YES
Copay: 50% copay per visit (intrauterine only) except for donor semen and donor
eggs and services related to their procurement and storage.
Max Cycles: A Plan physician determines if a member is fertile and the appropriate
number of drug-induced ovulation attempts for artificial/intrauterine insemination
IVF covered: YES (Supplemental ART)
Max Cycles: 1 per lifetime of any IVF/GIFT/ZIFT or cryopreserved embryo transfer
GIFT covered: YES (Supplemental ART)
Max Cycles: 1 per lifetime of any IVF/GIFT/ZIFT or cryopreserved embryo transfer
ZIFT covered: YES (Supplemental ART)
Max Cycles: 1 per lifetime of any IVF/GIFT/ZIFT or cryopreserved embryo transfer
Infertility drugs covered: Oral (Yes)
/
Injectables (Yes)
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Copay: 50% (generic)/50% (brand) per prescription, up to 100-day supply, when
deemed medically necessary, prescribed by a Plan physician and obtained at Plan
pharmacies
Max Cycles: Determined by a Plan physician
Plan Maximum (Medical):
Supplemental Infertility: Annual (NO)
/
Lifetime (NO)
Supplemental ART: 1 treatment of IVF/IVF/ZIFT per lifetime
Plan Maximum (RX): Annual (NO)
/
Lifetime (NO)
Supplemental Infertility: Annual (NO)
/
Lifetime (NO)
Supplemental ART: 1 treatment of IVF/IVF/ZIFT per lifetime
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ALL other covered services:
Supplemental Infertility: The preparation of semen for artificial/intrauterine
insemination (“sperm processing or sperm washing”) is only covered when considered
part of medically necessary treatment for the female member who is to be
inseminated.
For a binding and detailed description of benefits, exclusions and limitations,
please refer to your Evidence of Coverage and Disclosure Form.
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ALL exclusions:
Supplemental ART:
Services to reverse voluntary, surgically induced infertility are not covered. Services
related to donor semen and eggs and their procurement and storage are not covered.
This exclusion for semen and eggs (and services related to their procurement and
storage) does not apply to retrieval of eggs from a covered member for a covered
GIFT, ZIFT, or IVF treatment cycle.
The ART benefit covers only one treatment cycle in a member's lifetime. Services
provided to diagnose and treat non-member partners during the course of infertility
care for a member are not covered. For example, if the member is a female and her
male partner is not a Health Plan member, evaluation and treatment of male factor
infertility is the responsibility of the male partner's health plan.