23-1391 Help Members Get the Most from Infertility Treatment Coverage
Date: 11/29/23
Family planning benefits for infertility align with existing medical policies
Review the following to learn when Health Net plans cover infertility treatment, gamete intrafallopian transfer, artificial insemination and intrauterine insemination.
Keep in mind:
- Before beginning infertility treatment, establish a treatment plan. Remember to check the Schedule of Benefits for specific coverage of advanced reproductive technologies, in vitro fertilization and zygote intrafallopian transfer.
- The required copayments for infertility procedures typically do not apply to the out-of-pocket maximum. Refer to the introduction of the Schedule of Benefits to see if a member’s employer group plan is an exception.
- If a member has not conceived in a particular treatment plan, re-evaluate the plan and change the therapy. If the member is still unsuccessful, consider advanced treatment under the guidance of a reproductive endocrinologist or fertility specialist.
- The number of cycles, or a dollar amount limit of a particular treatment plan and assistive reproductive technologies, may be limited under the member’s plan. Consult the member’s Explanation of Coverage. Certain standard and advanced treatments are covered when specified conditions are met.
Diagnosis criteria
Effective as of January 1, 2024, diagnosis of infertility may be appropriate for members who have not yet gone through menopause and any of the following apply:
- The member has had coitus relations on a recurring basis for one year or more without use of contraception or other birth control methods which has not resulted in a pregnancy, or when a pregnancy did occur, a live birth was not achieved.
- The member does not have coitus with a male partner.
- A licensed physician’s determination of infertility, based on the member’s medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors.
Additional information
Relevant sections of Health Net’s provider operations manuals will be revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library on
Health Net’s provider portal > Provider Library under Quick Links, or go directly to Provider Library.
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by telephone or through the Health Net provider portal.
This information applies to Participating Physician Groups (PPGs), Primary Care Physicians and OB/GYNs. .