Fertility Services

Yale Health defines infertility as a person’s inability to reproduce either as a single individual or with a partner without medical intervention; or a licensed physician’s findings based on a patient’s medical, sexual, and reproductive history, age, physical findings, or diagnostic testing. Our goal is to provide programs and services that meet the needs of our members for fertility treatment, supporting every unique path to parenthood.

To avoid responsibility for the cost of services over these limits, members are urged to consult the Yale Health Claims Department to monitor the utilization of this benefit.

Eligibility for Fertility Services Benefit

To be eligible for the Fertility Services benefit, Yale Health members must meet at least one of the following criteria:

1. Couples where one or both members are diagnosed with infertility by a physician.
   1. For individuals with male reproductive anatomy, this is generally defined as failure to conceive with a fertile partner with female reproductive anatomy after one year of regular unprotected coitus.
   2. For individuals with female reproductive anatomy, this is generally defined as:
      1. For those under age 35, failure to conceive with a fertile partner with male reproductive anatomy after one year of regular unprotected coitus.
      2. For those aged 35 to 39, failure to conceive with a fertile partner with male reproductive anatomy after 6 months of regular unprotected coitus.
      3. There is no time requirement for those aged 40 and older, but to qualify for the Fertility Services benefit, they must have evidence of adequate ovarian function. This must be demonstrated by an unmedicated day 3 FSH of less than 19 mIU/mL on the current measurement and on all prior measurements and ongoing evidence of adequate ovarian function through other means (e.g. follicle counts, AMH, response to ovarian stimulation). This requirement is waived when oocyte retrieval is not required required because the patient already has their own previously cryopreserved oocytes or embryos.
2. Same-sex couples. This includes both same-sex male and same-sex female couples. For individuals with female reproductive anatomy, those aged 40 and older only qualify for the Fertility Services benefit if they have evidence of adequate ovarian function (see criteria above).
3. Single individuals. For individuals with female reproductive anatomy, those aged 40 and older only qualify for the Fertility Services benefit if they have evidence of adequate ovarian function (see criteria above).
4. Couples who qualify for medically indicated preimplantation genetic testing (PGT) because they are at risk for having a child with a clinically significant childhood-onset genetic disease.  This includes:
   1. One member of the couple carries a mutation for an autosomal dominant genetic disease.
   2. Both members of the couple carry the same mutation for an autosomal recessive genetic disease.
   3. A member of the couple carries a mutation for an X-linked genetic disease.
5. Individuals who qualify for medically indicated fertility preservation because they are facing infertility due to chemotherapy, pelvic radiotherapy (or other gonadotoxic therapy), gender-affirming hormone therapy, or medically necessary surgery that will impair fertility.
6. Individuals diagnosed by a physician with recurrent pregnancy loss.

Fertility services are only provided to eligible Yale Health members. If your partner is not a Yale Health member, then any services they receive are not covered under your benefit and must be billed to their own insurance.

The following individuals are ineligible for the Fertility Services benefit:

1. Individuals who have previously undergone a sterilization procedure, including couples where one or both individuals have previously undergone sterilization, regardless of whether the individual has undergone a reversal procedure.
2. Individuals with natural menopause, defined as those 40 years of age and older with 12 consecutive months of no menstruation and no other cause for amenorrhea.  This exclusion does not apply to those who were less than 40 years of age when they completed menopause, who are considered to have primary ovarian insufficiency (premature ovarian failure).
3. Individuals aged 40 and older, unless they have adequate ovarian function to result in a reasonable likelihood of successful fertility treatment (see criteria above).

Basic Fertility Services

Basic fertility services are covered for all individuals and couples eligible for the Fertility Services benefit.  Basic fertility services include the following:

1. Diagnosis and consultation with a network physician.
2. Infertility-related testing (including labs, imaging, semen analysis, sonohysterogram, and hysterosalpingogram).
3. Treatment to stimulate/induce ovulation.
4. Intrauterine insemination.

Regardless of plan type, Yale University provides a lifetime maximum Basic Fertility Services benefit of $20,000.

Advanced Fertility Services

Advanced fertility services extend beyond the basic infertility services and are available to members for whom pregnancy cannot be attained through less costly treatment(s) covered by this plan, including the basic fertility services. One of the following criteria must be met: 

1. Age 38 or above.
2. Failure to conceive after three cycles of intrauterine insemination.
3. Previously cryopreserved eggs or embryos will be used.
4. Primary ovarian insufficiency (premature ovarian failure).
5. Diminished ovarian reserve, diagnosed based on one of the following:
   1. POSEIDON Groups 2-4
   2. Bologna criteria:
      1. AMH < 1.2 ng/mL, and/or
      2. Antral follicle count < 5, and/or
      3. Prior cycle with < 4 oocytes retrieved (> 35 yo)
6. Confirmed diagnosis of tubal factor infertility, defined as:
   1. Bilateral tubal disease (e.g., salpingitis isthmica nodosum, tubal obstruction, absence, or hydrosalpinges).
   2. Endometriosis stage 3 or 4.
   3. Failure to conceive after pelvic surgery with restoration of normal pelvic anatomy (e.g., myomectomy of cavitary-obscuring myomata, resection of intrauterine adhesions or uterine septum, or surgical reconstruction of tubal disease):
      1. After regular egg-sperm contact for 6 months if less than 40 years of age
      2. After regular egg-sperm contact for 3 months if 40 years of age or older
   4. Unilateral hydrosalpinx with failure to conceive:
      1. After regular egg-sperm contact for 12 months if less than 40 years of age
      2. After regular egg-sperm contact for 6 months if 40 years of age or older
7. Male factor infertility, defined as total motile sperm less than 10 million/mL.
8. Need for medically indicated PGT-M or PGT-SR testing as outlined below.
9. Need for medically indicated fertility preservation as outlined below.
10. Pregnancy is contraindicated due to maternal medical condition or medically necessary teratogenic medication, and gestational surrogacy is planned.

Advanced Fertility services are:

1. Retrieval of oocytes (eggs)
   1. Coverage: Oocyte retrieval is covered when being done for purposes of an eligible fertility service.  Each oocyte retrieval cycle uses ½ cycle of benefit.
   2. Exclusions: Oocyte retrieval is not covered when being used for uncovered services (e.g. elective oocyte cryopreservation, or oocyte/embryo cryopreservation to circumvent normal reproductive aging).
2. Fertilization of oocytes
   1. Coverage: In-vitro fertilization of oocytes is covered when being done as part of eligible fertility services. Each oocyte fertilization cycle uses ½ cycle of benefit, unless it is combined with embryo transfer, in which case the oocyte fertilization and embryo transfer combined use ½ cycle of benefit.  Cryopreservation of embryos, which includes the first year of storage, is covered up to a lifetime maximum of $1,500 (for applicable plans only).
   2. Exclusions: In-vitro fertilization of oocytes is not covered when being used for uncovered services (e.g. non-medically indicated preimplantation genetic testing). Costs for storage of cryopreserved embryos beyond one year are not covered.
3. Intracytoplasmic sperm injection (ICSI)
   1. Coverage: Using ICSI for an oocyte fertilization cycle is covered for cycles using cryopreserved eggs, or if 2 of the following semen analysis criteria are outside the normal limits:
      1. Count
      2. Motility
      3. Strict morphology
   2. Exclusions: ICSI is not covered when being used for uncovered services.
4. Transfer of embryos
   1. Coverage: Transfer of embryos into a Yale Health member is covered when being done as part of authorized fertility services. Each embryo transfer uses ½ cycle of benefit, unless it is combined with oocyte fertilization as part of the same cycle, in which case the oocyte fertilization and embryo transfer combined use ½ cycle of benefit. Frozen embryo transfer uses ½ cycle of benefit.
   2. Exclusions: Embryo transfer into an individual who is not a Yale Health member is not covered. Embryo transfer into a gestational surrogate is not covered (see Uncovered Fertility Services below).
5. Preimplantation genetic testing for a gene mutation (PGT-M) or structural rearrangement (PGT-SR)
   1. Coverage: Medically indicated PGT-M (preimplantation genetic testing for known mutation) and PGT-SR (preimplantation genetic testing for known structural rearrangement) are covered when a member is at risk for having a child with a clinically significant childhood-onset genetic disease (see Eligibility for Fertility Services Benefit).
   2. Exclusions: Preimplantation genetic screening (PGS) and PGT-A (preimplantation genetic testing for aneuploidy) are not covered. Expanded carrier testing of embryos is also not covered.
6. Donor tissue
   1. Coverage: Coverage of donor oocytes (eggs), sperm, and embryos varies by plan, and it is only covered when medically necessary to establish fertility. Please check your Schedule of Benefits for coverage and limitations.
      1. Donor oocytes (eggs): Reimbursement for donor oocytes (cohort of 6-8 oocytes) is covered up to $20,000 per cohort, and reimbursement for each cohort uses one full cycle of benefit.
      2. Donor sperm: Purchase of donor sperm is reimbursed, and each $2,500 increment of reimbursement uses ¼ cycle of benefit.
      3. Donor embryos: Use of donated embryos is handled on a case-by-case basis and does not typically involve purchase of the donated embryos.  Each donated frozen embryo transfer uses ½ cycle of benefit as described above.
   2. Exclusions:
      1. Donor oocytes (eggs): Costs for transportation/shipping and storage of donor oocytes are not covered.
      2. Donor sperm: Costs for transportation/shipping and storage of donor sperm are not covered. For direct donor sperm, costs for processing and testing are not covered.
      3. Donor embryos: Costs for transportation/shipping and storage of donor embryos are not covered.
7. Medically indicated fertility preservation
   1. Coverage: Cryopreservation of sperm, oocytes, or embryos may be covered for individuals facing infertility due to chemotherapy, pelvic radiotherapy (or other gonadotoxic therapies), gender-affirming hormone therapy, or medically necessary surgery that will impair fertility. If approved, cryopreservation and the first year of storage is covered.
   2. Exclusions: Costs for sperm, oocyte, or embryo storage beyond 1 year are not covered. Elective cryopreservation is not covered.  Cryopreservation to circumvent reproductive aging in a healthy individual is not covered.

Here is a summary of benefit cycle amounts used for Advanced Fertility Services:

Additional Fertility Exclusions

1. Gestational surrogate: Surrogacy is a Yale University benefit, so charges associated with gestational surrogacy, including embryo transfer to a surrogate, are not covered by the plan.
2. Reciprocal IVF: Reciprocal IVF is a fertility treatment option for same-sex couples who both have ovaries. One partner undergoes egg retrieval, and the fertilized egg is then transferred to the other partner. Yale Health would not cover reciprocal IVF unless both members of the couple were Yale Health members and both met the criteria for IVF.
3. Futile services: Services that are not reasonably likely to result in successful fertility are not covered.
4. Experimental treatments: Experimental fertility procedures for which medical evidence is not sufficient for the American Society for Reproductive Medicine or a comparable organization to regard the procedure as an established medical practice are not covered.
5. Age limit: Fertility services are not covered for individuals age 55 and older.
6. Any drugs or products eligible for coverage under the Pharmacy benefit.