Benefit Limitation/Oocyte Retrieval Limitation

Section 2015.35  Benefit Limitation/Oocyte Retrieval Limitation a)         For treatments that include oocyte retrievals, coverage shall be required if the covered individual has been unable to attain a viable pregnancy, maintain a viable pregnancy, or sustain a successful pregnancy through reasonable, less costly medically appropriate infertility treatments for which coverage is available under the policy, plan, or contract.  This requirement shall be waived in the event that the covered individual or partner has a medical condition that renders the less costly treatments useless. b)         For treatments that include oocyte retrievals, coverage is not required if the covered individual has already undergone four completed oocyte retrievals, except that if a live birth follows a completed oocyte retrieval, then coverage shall be required for a maximum of two additional completed oocyte retrievals after the first live birth.  Such coverage applies to the covered individual per lifetime of that individual, for treatment of infertility, regardless of the source of payment. 1)         Following the final completed oocyte retrieval for which coverage is available, coverage for one subsequent procedure used to transfer the oocytes or sperm to the covered recipient or to a surrogate shall be provided. 2)         The policy or contract may provide a maximum number of completed oocyte retrievals for which the covered individual is eligible for coverage, which must be at least six (up to four cycles, plus an additional two after a live birth). c)         When the maximum number of completed oocyte retrievals has been achieved, except as provided by subsection (b)(1), infertility benefits required under this Part shall be exhausted except with respect to the transfer of retrieved oocytes or resulting embryos to the covered recipient or a surrogate and other medically necessary fertility services until the covered individual or surrogate is discharged to regular obstetrical care.  However, nothing in this Part shall limit the coverage required by Section 356z.32 of the Code.