Assisted Reproductive Technology

This policy covers Assisted Reproductive Technology (ART) services—including diagnostic infertility evaluation, IVF/ICSI/FET/GIFT/ZIFT, IUI/ICI, sperm and testicular sperm extraction, sperm washing, short‑term gamete/embryo cryopreservation, infertility‑related surgeries, and FDA‑approved infertility medications—when performed solely to treat infertility and when all applicable ART criteria are met. Coverage applies to persons meeting the policy definition of infertility (failure to conceive after 1 year if <35 or after 6 months if ≥35) and to specified indications (e.g., male‑factor infertility, HIV‑serodiscordant couples with an HIV‑positive male), but is available only if the member’s plan includes infertility benefits and requires specified documentation and eligibility thresholds (e.g., tubal patency, semen analyses, embryo-count and prior treatment requirements); pharmacy‑managed medications follow CP.PHAR.131, sperm washing is limited to male HIV‑positive/female HIV‑negative couples, cryopreservation is limited to short‑term (up to 1 year), and infertility from voluntary sterilization is excluded.