Point32 Fertility Services for Harvard Pilgrim Health Care Massachusetts Products (Large Group and Merged Market)(Eff. beginning 1.1.24) Form

This fertility benefit provides coverage for certain fertility services, to members who do not meet the definition of infertility under Massachusetts law, in an effort to support inclusive family building for all members, including those across sexual orientation and gender identity spectra and those without coparenting partners or those who do not meet infertility criteria from the Assisted Reproductive Technology Services Medical Necessity Guideline.

These Medical Necessity Guidelines includes the clinical coverage criteria for fertility services that are available when benefit coverage exists in accordance with applicable plan documents. Benefit coverage is limited to Massachusetts Large Group and Merged Market commercial products and employer groups that have elected this benefit.

Note: For members with documented infertility or who do not conceive using Intrauterine Insemination after four cycles, please refer to the Assisted Reproductive Technology Services MNG.

Clinical Guideline Coverage Criteria

• The following services are covered with prior authorization when eligibility and evaluation requirements are met

+ az . Point32Health companies 67725351 Fertility Services for Harvard Pilgrim Health Care Massachusetts Products (Large Group and Merged Market)

• Intrauterine Insemination (IUI)o Administered in the office setting with the support of a licensed clinician
• Donor sperm used for purposes of IUI, In-Vitro Fertilization (IVF), and reciprocal IVF services
• Donor egg, including the cost of donor egg, insemination, processing, and cryopreservation
• Reciprocal IVF
• Laboratory and other associated testing (blood testing, sperm testing, ultrasound) related to the covered fertility services listed above.

Eligibility Requirements for Fertility Services

The Member must meet all of the following:

1. The Member must be the recipient of the intended services
2. Coverage for services in this guideline are based on the Member's individual medical history and should demonstrate >5% chance of live birth

Evaluation Requirement

The Member must meet or submit ALL of the following:

For Members who can carry a pregnancy and are seeking IUI or IVF:

1. Ovarian Reserve Testing-Cycle Day 3
   • Follicle Stimulating Hormone (FSH) level ≤ 15 mIU/mlAND
   • Estradiol (E2) level ≤100 pg/mLOR
   • Anti-Mullerian Hormone (AMH) (documentation is required with reason why FSH/E2 cannot be performed)
2. Thyroid Stimulating Hormone (TSH) completed:
   • <35 years within two years
   • ≥35 years within one year
3. Rubella Status (all non-immune members must be vaccinated and wait one month thereafter before seeking approval for ART)
4. Uterine cavity evaluation
   • A uterine cavity evaluation (e.g., Hysterosalpingogram (HSG) or Hysterosalpingo-Contrast Sonography (HyCoSy) within one year prior to the initial ART cycle
   • Uterine cavity follow-up evaluation is required every two years
   • A uterine cavity evaluation is needed following a pregnancy that resulted in an antenatal, intrapartum, or postpartum complications

For Members seeking Reciprocal IVF:

1. Egg Donor Member:
   • Ovarian Reserve Testing-Cycle Day 3
     • Follicle Stimulating Hormone (FSH) level ≤ 15 mIU/mlAND
     • Estradiol (E2) level ≤100 pg/mLOR
     • Anti-Mullerian Hormone (AMH) (documentation is required with reason why FSH/E2 cannot be performed)
   • Thyroid Stimulating Hormone (TSH) completed:
     • <35 years within two years
     • ≥35 years within one year
2. Egg Recipient Member:
   • Ovarian Reserve Testing-Cycle Day 3
     • Follicle Stimulating Hormone (FSH) level ≤ 15 mIU/ml AND
     • Estradiol (E2) level ≤100 pg/mL OR
     • Anti-Mullerian Hormone (AMH) (documentation is required with reason why FSH/E2 cannot be performed)
   • Thyroid Stimulating Hormone (TSH) completed
     • <35 years within two years
     • ≥35 years within one year
   • Rubella Status (all non-immune members must be vaccinated and wait one month thereafter before seeking approval for ART)

Fertility Services for Harvard Pilgrim Health Care Massachusetts Products (Large Group and Merged Market)

Uterine cavity evaluation

1. A uterine cavity evaluation (e.g., Hysterosalpingogram (HSG) or Hysterosalpingo-Contrast Sonography (HyCoSy) within one year prior to the initial ART cycle
2. Uterine cavity follow-up evaluation is required every two years
3. A uterine cavity evaluation is needed following a pregnancy that resulted in an antenatal, intrapartum, or postpartum complications

Donor Eggs or Oocytes:

Coverage for donor eggs or oocytes is provided to members who do not have a partner that can produce fertilizable eggs. A semen analysis must be performed within one year. If the semen analysis is abnormal, 1 vial of sperm may be covered. Abnormal semen analysis is defined as:

1. <10 million total motile sperm/ejaculate (pre-wash specimen) or <3 million total motile sperm (post-wash specimen) on two separate semen analysis performed at least two weeks apart;
2. ≤1% normal forms (Strict Kruger Morphology)

Donor Sperm:

Coverage for donor sperm is provided to members who can carry a pregnancy when evaluation criteria for IUI, IVF, or Reciprocal IVF are met. Note: One vial of sperm may be provided per IUI treatment

Cryopreservation:

Clinical Coverage Criteria for Cryopreservation of Sperm, Oocyte, or Embryos

The Plan may authorize, with prior authorization, coverage for the harvest, procurement, and storage of sperm, oocytes, or embryos and said storage for up to 24 months in association with ongoing fertility care or when documentation confirms ONE of the following is met:

1. When a member is undergoing medical treatment that may result in infertility (e.g., chemotherapy, radiation, gender affirming services)
2. When there is a high probability of an adverse impact on the Member’s health and well-being (e.g., severe hyperstimulation syndrome)
3. Single embryo transfer requirements or the high risk of multiple gestations from the transfer of an excessive number of available embryos
4. When eggs cannot be fertilized during an authorized IVF cycle due to lack of sperm or sperm of poor quality on the day of egg procurement

Limitations

The Plan considers fertility services for all other indications not medically necessary and therefore not covered. In addition, the plan does not cover services for ANY of the following:

1. Services for individuals who do not have with a likelihood of ‘success’ (<5% chance of live birth)
2. Treatment and related expenses not otherwise outlined above when the Member is not the recipient of said services (e.g., gestational carrier or transfer of embryo to a gestational carrier, donor egg recruitment, or surrogacy related expenses) and drugs that are directly related to a stimulated ART cycle for anonymous or designated donor.
3. Sperm cryopreservation as a routine procedure for sperm backup in the absence of a confirmed physical or psychological diagnosis requiring cryopreservation

Fertility Services for Harvard Pilgrim Health Care Massachusetts Products (Large Group and Merged Market)

1. ART/fertility services (including but not limited to consultations, labs, radiology studies, infertility drugs, ART cycles, and other services to assess fertility and/or treat infertility in a member or a member’s partner) requested as a result of a prior voluntary sterilization or unsuccessful sterilization reversal procedure unless there is documentation that criteria (above) are met
2. ART/fertility services in cases in which normal embryos have been or will be discarded because of gender selection
3. ART/fertility services when clinical documentation indicates a member or member’s partner has active or uncontrolled alcohol use disorder or substance use disorder. Results of serum or urine drug screening may be requested before ART services are authorized
4. ART/fertility services for members who are actively smoking cigarettes and/or are using nicotine containing products such as gum, patches, or electronic cigarettes

9. Charges for the storage of eggs, sperm or embryos that remain in storage after the completion of approved fertility service beyond the authorization period described above
10. Compensation for the recruitment of egg donors including but not limited to testing, screenings, services fees, and charges
11. Chromosome studies of donor (sperm or egg)
12. Services or drugs directly related to non-covered services (when the procedure is outside the scope of the Medical Necessity Guidelines)
13. Cryopreservation, storage, and thawing of reproductive tissue (ovarian/testicular) (CPT codes 89335, 89344, and 89354 are considered experimental)
14. No coverage is provided for reciprocal IVF services for non-Members