Microsoft word - infertility benefits 10-05.doc

Infertility Benefits at a Glance
This document is a general overview of covered benefits for infertility services under BlueCare and Century
Preferred Health Plans as described in Public Act 05-196. For purposes of this overview, infertility means the
condition of a presumably healthy individual who is unable to conceive or produce conception or sustain a
successful pregnancy during a one-year period.
Covered Services Related to Infertility
Examples include, but are not limited to: exams, endometrial biopsy, diagnostic lab studies (such as sperm
isolation, semen analysis, and sperm antibody testing), hysterosalpingogram, ultrasound, laparoscopy,
hysteroscopy, artificial insemination, ovulation induction, intrauterine insemination, in-vitro fertilization,
uterine embryo lavage, embryo transfer, gamete intra-fallopian transfer, zygote intra-fallopian transfer, low
tubal ovum transfer, surgical treatment procedures (myomectomy for documented infertility) and microsurgery
for tubal pathology.
Covered Prescription Drugs
When used for the treatment of infertility, examples include, but are not limited to: Pergonal, Metrodin, Profasi,
Clomid, Serophene, Pregnyl, Chorionic Gonadotropin, Clomiphene Citrate, Lupron Kit, Progesterone,
Humegon, Repronex, Fertinex, Gonal-F and Follistim.

Note: Prescription drugs for the treatment of infertility should be submitted through the prescription drug program first.
Coverage Limitations
Examples include, but are not limited to:
ƒ Infertility benefits are available until the eligible members 40th birthday;
ƒ Ovulation induction coverage is limited to a lifetime max of 4 cycles;
ƒ Intrauterine insemination is limited to a lifetime max of 3 cycles;
ƒ In-vitro, GIFT, ZIFT and low tubal ovum transfer is limited to a maximum of two cycles combined with not
more than two embryo implantations per cycle-with each fertilization or transfer counting as one cycle; and ƒ Members must disclose if they had services under another carrier that were covered by that carrier.
Not Covered
The following are examples of services/expenses not mandated to be covered under this Act:
ƒ Donor costs;
ƒ Experimental and investigational procedures;
ƒ Reversal of surgical sterilization (male or female); and
ƒ Gestational carriers/surrogate parenting arrangements.
All infertility services require prior authorization. You may obtain prior authorization by calling the
number on the back of your identification card.

This document is a general overview and description of available infertility benefits for certain medically necessary covered services. It is not a legal
policy or contract. It is intended as a quick reference to inform you about your benefits. All benefits are subject to the provisions, limitations, and
exclusions in the BlueCare Health Plan or Century Preferred Subscriber Agreement, Certificate of Coverage or Summary Booklet and applicable
riders.

Source: https://1800insurancect.com/Health/client_service_forms/Anthem-Infertility%20Benefits-10-05.pdf