Infertility Services

If you are seeking help for infertility, SAMBA has a range of services available to you

People under the age of 35 who aren’t pregnant after one year of trying should consider seeing a healthcare provider. If you’re over 35 years of age, you may want to seek evaluation after six months of trying. Your chances of getting pregnant decrease with age.

SAMBA Infertility Medical Policy

Click here to view the SAMBA Health Benefit Plan’s infertility diagnosis, treatment and fertility preservation medical policy

SAMBA Infertility Benefits

	High Option members pay:	Standard Option members pay:
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)	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 or 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 - Benefits are limited to $1,000 per person, per calendar year/$5,000 per lifetime under the High Option and $800 per person, per calendar year/$3,500 per lifetime under the Standard Option.	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 Drugs Prescription drugs for the treatment of infertility - Benefits for IVF-related drugs are limited to three (3) cycles per person, per calendar year under both High Option and Standard Option.	Regular Plan benefits, cost sharing, and rules will apply depending on the fertility drug that is prescribed and the category in which your prescription falls (generic, preferred brand name, non-preferred brand name, or specialty)	Regular Plan benefits, cost sharing, and rules will apply depending on the fertility drug that is prescribed and the category in which your prescription falls (generic, preferred brand name, non-preferred brand name, or specialty)
Services not covered include: 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 manipulated. These treatments include: - In vitro fertilization (IVF) (see Section 5(f). Prescription Drug Benefits on page 78 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

Infertility is defined as not being able to conceive after 1 year (or longer) of egg sperm contact. Because infertility in females (or individuals with female reproductive organs) is known to decline steadily with age, some providers evaluate and treat individuals aged 35 or older after 6 months of egg sperm contact. Infertility may also be established through an evaluation based on medical history and diagnostic testing.