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Effective Date:
a)
This policy
will apply to all services performed on or after the above Revision date which
will become the new effective date.
b)
For all
services referred to in this policy that were performed before the revision
date, contact customer service for the rules that would apply.
1)
This policy
describes Infertility coverage under the Federal Employees Health Benefit
Program.
a)
If you are
not enrolled in that program, please go to BI057 for information about
infertility coverage.
2)
Infertility
includes all services rendered on behalf of an enrollee that are intended to
learn why there is a delay in conception or to increase the likelihood of
conception.
3)
All
services related to infertility treatment require pre-authorization.
a)
If you are
receiving services from an in-network provider, that provider is responsible to
obtain the pre-authorization.
b)
If you are
receiving services from an out-of-network provider, you are responsible for all
pre-authorizations.
4)
The Federal
Employees Health Benefit Program covers services related to the diagnosis,
evaluation and treatment of infertility, including intra-vaginal insemination,
but not including:
a)
In Vitro
Fertilization
b)
Embryo
Transfer
c)
Gamete
Intrafallopian Transfer (GIFT)
d)
Zygote
Intra-Fallopian Transfer (ZIFT)
e)
Intracervical Insemination
f)
Intrauterine Insemination
g)
Medications
used to treat infertility
5)
If you have
questions about your financial participation in the diagnosis or treatment of
infertility, please see your coverage handbook.
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