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399 Revolution Drive, Suite 810, Somerville, MA 02145 | AllWays Health Partners includes AllWays Health Partners, Inc. and AllWays Health Partners Insurance Company 1 Medical Policy Assisted Reproductive Services/Infertility Services Document Number: 002 *Commercial and Qualified Health Plans MassHealth Authorization required X No notification or authorization Not covered X *Not all commercial plans cover this service, please check plan s benefit package to verify coverage. Contents Overview .. 2 Coverage Guidelines .. 2 MassHealth, and Certain Custom Plans .. 2 Covered Services/Procedures .. 3 General Eligibility Coverage Criteria .. 3 SERVICE -SPECIFIC INFERTILITY COVERAGE FOR MEMBERS WITH UTERI and OVARIES .. 5 Artificial Insemination (AI)/Intrauterine Insemination (IUI) .. 5 Conversion from IUI to In Vitro Fertilization (IVF) .. 6 In Vitro Fertilization (IVF) for Infertility.
Frozen embryo transfer (FET); 5. Single embryo transfer (SET); 6. Intra-Cytoplasmic Sperm Injection (ICSI); 7. Donor Egg for Infertility; 8. Donor Sperm or Therapeutic Donor Insemination (TDI) Services for Infertility; 9. Donor Egg/Sperm When There is a Risk of Transmitting a Genetic Disorder for a serious genetic ...
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