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§4252.__Infertility coverage |
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| | 1.__Definition.__For the purposes of this section, | "infertility" means the disease or condition that results in | the abnormal function of the reproductive system such that a | male is not able to impregnate a female or a female is not | able to become pregnant and maintain a pregnancy to full term | after one year of attempting pregnancy. |
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| | 2.__Coverage.__All group health maintenance organization | contracts that provide for coverage for pregnancy-related | benefits must provide coverage for the diagnosis and treatment | of infertility, including, but not limited to, in vitro | fertilization, embryo transfer, artificial insemination, | gamete intrafallopian tube transfer, zygote intrafallopian | tube transfer and low tubal ovum transfer. |
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| | 3.__Limits.__The coverage required by this section is | subject to the following conditions: |
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| A.__The female partner must be 21 years of age or older | and under 45 years of age; |
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| B.__For a policy that provides prescription drug coverage, | the policy may not impose special restrictions on | prescription medications or a restriction or limitation on | the number of procedures used for infertility diagnosis or | treatment, except as provided in this subsection; |
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| C.__Coverage for procedures for intrauterine insemination | with ovarian stimulation and procedures requiring oocyte | retrieval may be limited in accordance with the following. |
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| (1)__The policy may require that the covered | individual has been unable to attain or sustain a | pregnancy through reasonable, less costly medically | appropriate infertility treatments for which coverage | is available under the policy or contract. |
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| (2)__The policy may limit the covered individual to a | maximum of 6 completed intrauterine inseminations | with ovarian stimulation, except that if the | individual has a living child, then the policy may | limit coverage to 3 completed intrauterine | inseminations with ovarian stimulation. |
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| (3) The policy may limit the covered individual to a | maximum of 4 completed oocyte retrievals, except that | if the individual has a living child, then the policy | may limit coverage to 2 completed oocyte retrievals. |
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