Policy Issued By: AllWays Health Partners

Policy Title: Assisted Reproductive Services/Infertility Services

Fertility Preservation:

In Vitro Fertilization (IVF) for Member not in Active Infertility Treatment

AllWays Health Partners covers one cycle of IVF for the purpose of egg retrieval, processing and fertilization and a single cryopreservation of eggs/embryos for up to one year, when there is documentation that a member will be undergoing medical or surgical treatment (e.g. chemotherapy, radiation, gender affirming treatment), that is likely to result in permanent infertility.

Cryopreservation of Eggs/Embryos

[Female-assigned] member will be undergoing medical or surgical treatment (e.g. chemotherapy, radiation, gender affirmation etc) excluding voluntary sterilization that is likely to result in permanent infertility, and AllWays Health Partners has authorized an IVF cycle for stimulation and retrieval. Cryopreservation of eggs/embryos will be covered for up to one year from the time of the egg retrieval.

Cryopreservation of Sperm

[Male-assigned] member will be undergoing medical or surgical treatment (e.g. chemotherapy, radiation, gender affirmation ) excluding voluntary sterilization that is likely to result in permanent infertility. In this case the male member and/or couple do not need to be already receiving AllWays Health Partners -authorized in infertility services. There must be a >5% probability of a future live birth using the member’s cryopreserved sperm.

Policy Issued By: AllWays Health Partners

Policy Title: Gender Reassignment Surgery

Fertility Preservation:

AllWays Health Partners covers services related to fertility preservation in members undergoing gender

affirming procedures. Related policy: Assisted Reproductive Services/Infertility Services medical policy.

Policy Issued By: Blue Cross Blue Shield of Illinois

Policy Title: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Fertility Preservation:

Procurement, cryopreservation/freezing, storage/banking, and thawing of reproductive tissues, such as oocytes, ovaries, embryos, spermatozoa, and testicular tissue may be considered medically necessary for individuals with gender dysphoria because gender reassignment services, such as long-term cross-sex hormone therapy or surgical procedures, may render an individual infertile whether or not the individual has reproduced in the past.

See related policy:

OB402.023 Reproductive Technologies or Techniques and Related Services

Policy Issued By: Blue Cross Blue Shield of Massachusetts

Policy Title: Gender Affirming Services (Transgender Services)

Fertility Preservation:

Oocyte, embryo, or sperm retrieval, freezing and storage for up to 24 months for transgender members prior to undergoing hormone therapy or genital sex reassignment surgery may be considered MEDICALLY NECESSARY. (See medical policy #086, Infertility Diagnosis and Treatment)

• Per subscriber certificate language, cryopreservation is limited to one cycle only.

Policy Issued By: Blue Cross Blue Shield of Minnesota

Policy Title: Gender Affirming Procedures for Gender Dysphoria

Fertility Preservation:

Preservation of fertility is subject to the member’s contract benefits. This includes but is not limited to procurement, cryopreservation/freezing, storage/banking, and thawing of reproductive tissues, such as oocytes, ovaries, embryos, spermatozoa, and testicular tissue.

Policy Issued By: Blue Cross Blue Shield of Montana

Policy Title: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Fertility Preservation:

Procurement, cryopreservation/freezing, storage/banking, and thawing of reproductive tissues, such as oocytes, ovaries, embryos, spermatozoa, and testicular tissue may be considered medically necessary for individuals with gender dysphoria because gender reassignment services, such as long-term cross-sex hormone therapy or surgical procedures, may render an individual infertile whether or not the individual has reproduced in the past.

See related policy:

OB402.023 Reproductive Technologies or Techniques and Related Services

Policy Issued By: Blue Cross Blue Shield of New Mexico

Policy Title: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Fertility Preservation:

Procurement, cryopreservation/freezing, storage/banking, and thawing of reproductive tissues, such as oocytes, ovaries, embryos, spermatozoa, and testicular tissue may be considered medically necessary for individuals with gender dysphoria because gender reassignment services, such as long-term cross-sex hormone therapy or surgical procedures, may render an individual infertile whether or not the individual has reproduced in the past.

See related policy:

OB402.023 Reproductive Technologies or Techniques and Related Services

Policy Issued By: Blue Cross Blue Shield of Oklahoma

Policy Title: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Fertility Preservation:

Procurement, cryopreservation/freezing, storage/banking, and thawing of reproductive tissues, such as oocytes, ovaries, embryos, spermatozoa, and testicular tissue may be considered medically necessary for individuals with gender dysphoria because gender reassignment services, such as long-term cross-sex hormone therapy or surgical procedures, may render an individual infertile whether or not the individual has reproduced in the past.

See related policy:

OB402.023 Reproductive Technologies or Techniques and Related Services

Policy Issued By: Blue Cross Blue Shield of Texas

Policy Title: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Fertility Preservation:

Procurement, cryopreservation/freezing, storage/banking, and thawing of reproductive tissues, such as oocytes, ovaries, embryos, spermatozoa, and testicular tissue may be considered medically necessary for individuals with gender dysphoria because gender reassignment services, such as long-term cross-sex hormone therapy or surgical procedures, may render an individual infertile whether or not the individual has reproduced in the past.

See related policy:

OB402.023 Reproductive Technologies or Techniques and Related Services

Policy Issued By: Boston Medical Center HealthNet Plan / Well Sense

Policy Title: Gender Affirmation Surgeries

Fertility Preservation:

Feminizing/masculinizing hormonal therapy and/or gender affirmation surgeries may limit the member’s fertility. Plan medical criteria for infertility services (covered for some Plan products) are listed in the Plan’s Infertility Services medical policy, policy number OCA 3.725; this medical policy and the member's applicable benefit documents are available at www.bmchp.org for BMC HealthNet Plan members.

Policy Issued By: HMSA

Policy Title: Gender Identity Services

Fertility Preservation:

Fertility counseling is covered (subject to Limitations and Administrative Guidelines) when all of the following criteria are met:

1. Fertility counseling is provided by a qualified health care professional;
2. The service is provided prior to removal of testes or ovaries; and
3. The counselor documents that the patient has been advised about contraceptive use, effects of transition on fertility, and options for fertility preservation and reproduction

Policy Issued By: Harvard Pilgrim Health Care

Policy Title: Transgender Health Services

Fertility Preservation:

Harvard Pilgrim Health Care (HPHC) also covers retrieval, cryopreservation, and storage (up to one year) of sperm or eggs when documentation confirms an eligible member with gender dysphoria/gender incongruence will be undergoing gender reassignment treatment that is likely to result in infertility.

Policy Issued By: Harvard Pilgrim Health Care (Stride Medicare Advantage)

Policy Title: Transgender Health Services

Fertility Preservation:

HPHC also covers retrieval, cryopreservation, and storage (up to one year) of sperm or eggs when documentation confirms an eligible member with gender dysphoria/gender incongruence will be undergoing gender reassignment treatment that is likely to result in infertility.

Policy Issued By: University Health Alliance

Policy Title: Gender Identity Services

Fertility Preservation:

Fertility counseling is covered (subject to Limitations and Administrative Guidelines) when all of the following criteria are met:

1. Fertility counseling is provided by a qualified health care professional;
2. The service is provided prior to removal of testes or ovaries; and
3. The counselor documents that the patient has been advised about contraceptive use, effects of transition on fertility, and options for fertility preservation and reproduction.