Infertility Treatment

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Ancillary

Some plans cover specific infertility services as referenced in the member's Evidence of Coverage (EOC) or Certificate of Insurance (COI). Before beginning infertility treatment, the member's treating practitioner must establish a treatment plan. Refer to the Schedule of Benefits for specific information concerning plans that cover gamete intrafallopian transfer (GIFT). If these benefits have not been purchased, Health Net must notify the member in writing of coverage limitations.

If a member has not conceived in a particular treatment plan, the member’s treating practitioner should re-evaluate the plan and change the therapy. If the member is still unsuccessful, advanced treatment under the guidance of a reproduction endocrinologist or fertility specialist should be considered. The treatments below are covered when the following specified conditions are met:

  • Artificial insemination (AI), intrauterine insemination (IUI), GIFT and sperm washing - Covered when used in treatment of infertility (ovulation sticks are not covered)
  • IVF/ZIFT - Only certain plans cover IVF or ZIFT. Refer to the Schedule of Benefits for specific plan information

Refer to the Schedule of Benefits (SOB) for availability of infertility treatment; this is also referenced within the member’s Evidence of Coverage. The treatment used for each infertile member may be different and should be individualized based on medical indications. Most Health Net plans subject infertility services to a 50 percent copayment. The copayment amount is based on the percent copayment multiplied by the average wholesale price or the actual cost of the injected substance, whichever is less.

The required copayments for infertility procedures may or may not apply to the out-of-pocket maximum (OOPM). Refer to the Introduction pages of the Schedule of Benefits for a list of exception groups.

GIFT is covered when:

  • Plan covers standard infertility treatments/benefits
  • GIFT procedure is medically indicated
  • GIFT is performed by a reproductive endocrinologist or fertility specialist