Infertility Treatment
Provider Type
- Physicians
- Ancillary
- Participating Physician Groups (PPG)
Some plans cover specific infertility services as referenced in the member's Evidence of Coverage (EOC). Before beginning infertility treatment, the member's treating provider 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 provider 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 - All plans cover IVF or ZIFT. Refer to the Schedule of Benefits for specific plan information
Refer to the Schedule of Benefits 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. Applicable deductible or copayment requirements apply to any services and supplies required for Iinfertility services. For example, if the infertility service requires an office visit, then the office visit copayment will apply.
The required copayments for infertility procedures 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 the:
- Plan covers standard infertility treatments/benefits.
- GIFT procedure is medically indicated.
- GIFT is performed by a reproductive endocrinologist or fertility specialist.
Infertility Treatment (Ancillary and PPGs only)
Infertility means a condition or status characterized by any of the following:
A licensed physician’s findings, based on a patient’s medical, sexual, and reproductive history; age; physical findings; diagnostic testing; or any combination of those factors. This definition shall not prevent testing and diagnosis of infertility before the 12-month or 6-month period to establish infertility in item 3 below.
A person’s inability to reproduce either as an individual or with their partner without medical intervention.
The failure to establish a pregnancy or to carry a pregnancy to live birth after regular, unprotected sexual intercourse. For purposes of this definition, “regular, unprotected sexual intercourse” means no more than 12 months of unprotected sexual intercourse for a person under age 35 years or no more than 6 months of unprotected sexual intercourse for a person age 35 years or older. Pregnancy resulting in miscarriage does not restart the 12-month or 6-month time period to qualify as having infertility.
Infertility services is a required benefit for large employer group plans and an optional benefit for small employer group plans. When Health Net covers infertility treatment, coverage includes procedures consistent with established medical practices in the treatment of infertility by licensed physicians and surgeons including, but not limited to:
- Diagnosis and diagnostic tests.
- Artificial insemination (AI), intrauterine insemination (IUI) and gamete intrafallopian transfer (GIFT). Some custom employer group plans include coverage of assisted reproductive technologies (ART), in vitro fertilization (IVF) and zygote intrafallopian transfer (ZIFT).
- Covered services include:
- Prescription drugs.
- Professional services
- Inpatient and outpatient care.
- Treatment by injections.
Infertility prescription drugs are subject to the applicable Tier 1, 2 or 3 drug copayments as listed in the member’s Schedule of Benefits.
Note: Large group plans can be in the Specialty Tier and small groups can be in Tier 4.
Before beginning infertility treatment, the member's treating provider must establish a treatment plan.
If a member has not conceived in a particular treatment plan, the member's treating provider should re-evaluate the plan and change the therapy. If the member is still unsuccessful, advanced treatment under the guidance of a reproductive endocrinologist or fertility specialist should be considered. The number of completed oocyte retrieval cycles may be limited under the member's plan. Consult the member's Evidence of Coverage. The standard and advanced treatments below are covered when the specified conditions are met.
Standard Infertility Treatments
IUI may be performed using either the partner's sperm or donor sperm.
Donation, storage and banking of member or donor sperm are not covered.
GIFT is covered when the:
- Plan covers standard infertility treatments/benefits
- GIFT procedure is medically indicated
- GIFT is performed by a reproductive endocrinologist or fertility specialist licensed in the field
The required copayment for infertility procedures apply to the out-of-pocket maximum (OOPM). Refer to the introduction of the Schedule of Benefits for a list of exception groups.
Advanced Infertility Treatments
ART, IVF and ZIFT are advanced infertility treatment procedures.
For plans that cover ART, but limit the services to dollar limits, or a specified number of cycles per lifetime, ART is defined as:
- All office visits, procedures, blood work, and ultrasounds performed in preparation for oocyte retrieval.
- Retrieval of the oocyte itself (maximum of three completed oocyte retrievals).
- Culture and fertilization of the oocyte.
- Embryo transfer – unlimited.
A cycle is counted toward the lifetime maximum once the member has had their oocytes retrieved, whether or not there is fertilization of the oocyte.
Before a member is eligible for ART coverage, alternate treatments must be attempted without success. The treatment used for each infertile member may be different and should be individualized based on medical indications. Applicable deductible or copayment requirements apply to any services and supplies required for infertility services. For example, if the infertility service requires an office visit, then the office visit copayment will apply.
The required copayments for infertility procedures apply to the OOPM. Refer to the Introduction of the Schedule of Benefits for a list of exception groups.
Exclusions and Limitations
General infertility services that are not covered include:
- Ovulation kits.
- Partner's diagnosis and treatment if the partner is not covered by Health Net.
- Benefits for reversal of voluntary sterilization unless otherwise stated by the member's EOC.
- Infertility treatment needed as a result of prior voluntary sterilization.
- Donation, storage and banking of member or donor sperm or ova for future use.
- Unless otherwise stated in the EOC, the testing, storage and transport fees or any other charges incurred.
- Sperm washing when used in preparation for a non-covered procedure.
- Surrogacy or gestational carriers unless the surrogate is a Health Net member who has been diagnosed with infertility. When compensation is obtained for the surrogacy, Health Net or the participating provider may have a lien on such compensation to recover its medical expense.
- Gender selection.
- Donor eggs for women with genetic oocyte defects.
- Donor sperm for men with genetic sperm defects.
- Genetic engineering.
- Co-culture of embryos.