TREATMENT OF INFERTILITY - Oxford Health Plans

• Assisted oocyte fertilization, microtechnique;• Assisted embryo hatching, microtechniques;• Oocyte identification from follicular fluid;• Preparation of embryo for transfer (any method);• Sperm identification from aspiration (other than seminal fluid);• Ultrasonic guidance for aspiration of ova, imaging and supervision;• Intracytoplasmic sperm injection. (ICSI)Religious Employer:A religious employer may request a contract without coverage for infertility services (e.g., in vitrofertilization, embryo transfer, artificial insemination and intracytoplasmic sperm injection [ICSI])that are contrary to the religious employer's bona fide religious tenets.• Note: A religious employer is defined in CT as an employer that is a "qualified churchcontrolledorganization" as defined in 26 USC 3121 or a church-affiliated organization.EligibilityIn order to be eligible for infertility benefit coverage the Member must meet infertility, agecoverage and prior procedure criteria listed below:1. Infertility Criteria (must meet one):o Inability to achieve pregnancy after 12 months of unprotected heterosexualintercourse oro Women aged 35 and older who are unable to achieve pregnancy after 6 monthsof unprotected heterosexual intercourse oro Women with documented follicle stimulating hormone (FSH) levels less than orequal to 19 mIU/ml on day 3 of the menstrual cycle oro Women who have not met time criteria for failure to conceive, but who have adocumented anatomic variant resulting in the inability to achieve pregnancy (e.g.,severe pelvic inflammatory disease, endometriosis, or ectopic pregnancyrequiring surgical removal of both fallopian tubes) oro Males with anatomical variants such as aspermia or varicocele resulting in aninability to reproduce.2. Age criteria- applies to Member being treated [(male or female) (must meet both)]:o Minimum age is 21 years ando Maximum age is 44 years• Exception: If an eligible Member has initiated a cycle of treatment and,by virtue of having a birthday, exceeds the maximum eligible age prior tocompletion of the cycle, the treatment will be covered to the nearestlogical endpoint:ooFor Artificial Insemination: Ovulation induction initiated prior tobirthday: ovulation induction in progress and subsequentinsemination will be covered.Other Advanced Procedures (e.g. IVF, GIFT, etc): Cyclestimulation initiated prior to birthday: cycle stimulation inprogress, subsequent ovum retrieval, fertilization, culture andembryo transfer will be covered unless the benefit has beenexceeded.3. Coverage criteria (must meet all):o Treatment is limited to Oxford insured Members ando Benefit has not been exceeded andTreatment of Infertility: Clinical Policy (Effective 10/01/2013)©1996-2013, Oxford Health Plans, LLC4