PM - Section 16 - Family Planning Infertility Form

Section Sixteen Family Planning and Infertility

Fidelis Care Provider Manual

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V23.0-03/01/2023

16.1 FAMILY PLANNING and INFERTILITY SERVICES Fidelis Care covers family planning services and certain other reproductive health care services.
Members do not need a referral from their PCP and should present their Fidelis Care Member ID card. Members can obtain the following family planning services through Fidelis Care: birth control drugs, birth control devices (IUDs and diaphragms) that are available with a prescription, plus emergency contraception, sterilization, pregnancy testing, prenatal care, and abortion services. Members can also see a family planning provider for HIV and sexually transmitted infection (STI) testing and treatment and counseling related to their test results. Screenings for cancer and other related conditions are also included in family planning visits. Fidelis Care notified its primary care providers, obstetricians, and gynecologists, and certain other specialties, that Fidelis Care covers reproductive and family planning services as a standard benefit. Members who choose to see a provider who is not in the Fidelis Care network may still be able to get these services from a provider that accepts Medicaid. If a member does not use one of our network providers for these services, they should use their New York State Medicaid card. As a reference, members can call the New York State Growing Up Healthy Hotline at (1-800-522-5006).
Starting April 1st, 2023, all NYS Medicaid Managed Care members (including HARP) will receive their pharmacy benefits from NYRx, the Medicaid Pharmacy Program.

NYRx covers pharmaceuticals and injectables on a fee-for-service basis at the member's local retail pharmacy, through a members pharmacy benefit. The pharmacy will bill Medicaid directly for these drugs. Magellan will be administering the NYRx program for New York State. Providers can contact Magellan directly for Prior Authorizations, clinical concerns, or PDP questions at 1-877-309-9493. The NYS Medicaid Program requires prior authorization for certain drugs not on the preferred drug list. Please refer to its website: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf for a list of preferred medications and those requiring prior authorization.
Ovulation Induction and Infertility Infertility is defined as a condition characterized by the inability to conceive, defined by the failure to establish a clinical pregnancy after twelve months of regular, unprotected sexual intercourse for individuals 21-34 years of age, or after six months for individuals 35-44 years of age.

Ovulation enhancing drugs and related medical services are covered when billed with the appropriate infertility diagnosis codes: E22.1, E28 through E28.x, E23.0, L68.0, N97.0 or Z31.41 and when performed solely for the intent to establish pregnancy. Related lab services are covered.
The following services are considered medically necessary when performed solely for the treatment of infertility, with the intent to establish pregnancy, in an individual in who fertility would naturally be expected when meeting clinical criteria. Females:

1. FDA approved medications (for non-Medicaid Managed Care and HARP plans): clomiphene, bromocriptine, letrozole and tamoxifen covered as a group and not individually for a benefit limit of 3 cycles of treatment per lifetime.
2. Office visits
3. Hysterosalpingograms
4. Pelvis ultrasounds: for a benefit limit of 3 per cycle and a combined lifetime limit of 10.
   o to monitor the ovulation induction o to diagnose Polycystic ovary syndrome

Section Sixteen Family Planning and Infertility

Fidelis Care Provider Manual

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V23.0-03/01/2023

16.2

5. Blood testing
   o to diagnose the cause of anovulation o to monitor the ovulation induction.