Infertility Services

Diagnosis and treatment of infertility limited to:

• Initial diagnostic tests and procedures rendered only to identify the cause of infertility
• Medical or surgical procedures rendered to create or enhance fertility, except as shown in Not Covered
• Artificial insemination (AI) procedures, limited to the following:
  – Intravaginal insemination (IVI)
  – Intracervical insemination (ICI)
  – Intrauterine insemination (IUI)
  

Note: Fertility drugs, including IVF-related drugs up to three (3) cycles per year, are covered under Section 5(f). Prescription Drug Benefits.

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

PPO: 20% of the Plan allowance

Non-PPO: 45% of the Plan allowance and any difference between our allowance and the billed amount

• Fertility preservation procedures (retrieval of and freezing of eggs and sperm) for members facing the possibility of infertility caused by chemotherapy, pelvic radiotherapy, other gonadotoxic therapies, ovary or testicle removal for treatment of disease, or medical or surgical gender transition treatment

Note: Benefits are limited to $1,000 per person, per calendar year/$5,000 per lifetime under the High Option and $800 per per person, per calendar year/$3,500 per lifetime under the Standard Option.

Prior approval is required. If prior authorization is not obtained, no benefits will be payable and claims will be denied. Contact Cigna/CareAllies at 800-887-9735.

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

PPO: 20% of the Plan allowance

Non-PPO: 45% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Infertility services after voluntary sterilization
  
• Assisted reproductive technology (ART) procedures and related services and supplies related to any fertility treatments in which eggs or embryos are manioulated. These treatments include:
   – In vitro fertilization (IVF) (see Section 5(f). Prescription Drug Benefits for coverage of IVF-related drugs up to three (3) cycles per year)
   – Embryo transfer and gamete intra-fallopian transfer (GIFT)– Zygote intra-fallopian transfer (ZIFT)– Any procedure, service or supply involving the handling of eggs or embryos
• Cost of donor sperm or egg
• Expenses for sperm collection and storage, except as listed above
• Elective preservation for reasons other than listed above
• Surrogacy (host uterus/gestational carrier)
• Preimplantation genetic diagnosis (PGD)
• Commercially available over-the-counter home ovulation prediction test kits or pregnancy test kits

 All Charges

All Charges