Common use of Fertility Services Clause in Contracts

Fertility Services. This benefit has one or more exclusions as specified in the Exclusions Section. Male vasectomies are covered except for under high-deductible individual or group health plans until an insured’s deductible has been met. Tubal ligation/sterilization is a covered benefit. This benefit has one or more exclusions as specified in the Exclusions Section. Coverage is provided for diagnosing, monitoring, and controlling of disorders of Genetic Inborn Errors of Metabolism (IEM) where there are standard methods of treatment, when Medically Necessary and subject to the Limitations, Exclusions, and Prior Authorization requirements listed in this Agreement. Coverage for the treatment of genetic inborn errors of metabolism are provided with the same Durational limits, caps, deductibles, coinsurance and copayments as any other illnesses. Medical services provided by licensed Healthcare Professionals, including Practitioners/Providers, dieticians and nutritionists with specific training in managing Members diagnosed with IEM are Covered. Covered Services include: • Nutritional and medical assessment. • Newborn Screening for Metabolic Diseases. • Clinical services. • Biochemical analysis. • Medical supplies. • Prescription Drugs/Medications – refer to Prescription Drugs/Medications Section. • Corrective lenses for conditions related to Genetic Inborn Errors of Metabolism. • Nutritional management. • Special Medical Foods are dietary items that are specially processed and prepared to use in the treatment of Genetic Inborn Errors of Metabolism to compensate for the metabolic abnormality and to maintain adequate nutritional status when we approve the Prior Authorization request and when provided under the on-going direction of a qualified and licensed healthcare Practitioner/Provider team. Special medical foods may be prescribed for other medically necessary conditions. This does not include coverage of nutritional items/food supplements that are available over-the counter and/or without prescription. • One pair of standard (non-tinted) eyeglasses (or contact lenses if Medically Necessary) is Covered within 12 months after cataract surgery or when related to Genetic Inborn Error of Metabolism. This includes the Eye Refraction examination, lenses and standard frames. Refer to your Summary of Benefits and Coverage for applicable Cost-Sharing amounts (office visit Copayments, Inpatient Hospital, outpatient facility, Prescription Drug/Medications and other related Deductibles, Coinsurance and/or Copayments).‌‌ Genetic/genomic testing means an analysis of human DNA, RNA, chromosomes, proteins, or metabolites, if the analysis detects genotypes, mutations, or chromosomal changes. However, a genetic test does not include an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition. Genetic testing is not used as a screening test. Accordingly, a test to determine whether an individual has a BRCA1 or BRCA2 variant is a genetic test. Similarly, a test to determine whether an individual has a genetic variant associated with hereditary nonpolyposis colorectal cancer is a genetic test. However, an HIV test, complete blood count, cholesterol test, liver function test, or test for the presence of alcohol or drugs is not a genetic test. Genetic testing requires Prior Authorization.

Fertility Services. This benefit has one or more exclusions as specified in the Exclusions Section. Male vasectomies are covered except for under high-deductible individual or group health plans until an insured’s deductible has been met. Tubal ligation/sterilization is a covered benefit. This benefit has one or more exclusions as specified in the Exclusions Section. Coverage is provided for diagnosing, monitoring, and controlling of disorders of Genetic Inborn Errors of Metabolism (IEM) where there are standard methods of treatment, when Medically Necessary and subject to the Limitations, Exclusions, and Prior Authorization requirements listed in this Agreement. Coverage for the treatment of genetic inborn errors of metabolism are provided with the same Durational limits, caps, deductibles, coinsurance and copayments as any other illnesses. Medical services provided by licensed Healthcare Professionals, including Practitioners/Providers, dieticians and nutritionists with specific training in managing Members diagnosed with IEM are Covered. Covered Services include: • Nutritional and medical assessment. • Newborn Screening for Metabolic Diseases. • Clinical services. services.‌ • Biochemical analysis. • Medical supplies. • Prescription Drugs/Medications – refer Refer to Prescription Drugs/Medications Section. • Corrective lenses for conditions related to Genetic Inborn Errors of Metabolism. • Nutritional management. • Special Medical Foods are dietary items that are specially processed and prepared to use in the treatment of Genetic Inborn Errors of Metabolism to compensate for the metabolic abnormality and to maintain adequate nutritional status when we approve the Prior Authorization request and when provided under the on-going direction of a qualified and licensed healthcare Practitioner/Provider team. Special medical foods may be prescribed for other medically necessary conditions. This does not include coverage of nutritional items/food supplements that are available over-the the-counter and/or without prescription. • One pair of standard (non-tinted) eyeglasses (or contact lenses if Medically Necessary) is Covered within 12 months after cataract surgery or when related to Genetic Inborn Error of Metabolism. This includes the Eye Refraction examination, lenses and standard frames. Refer to If your child needs dental or eye care in your Summary of Benefits and Coverage for applicable Cost-Sharing amounts (office visit Copayments, Inpatient Hospital, outpatient facility, Prescription Drug/Medications and other related Deductibles, Coinsurance and/or Copayments).‌‌ Copayments). Genetic/genomic testing test means an analysis of human DNA, RNA, chromosomes, proteins, or metabolites, if the analysis detects genotypes, mutations, or chromosomal changes. However, a genetic test does not include an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition. Genetic testing is not used as a screening test. Accordingly, a test to determine whether an individual has a BRCA1 or BRCA2 variant is a genetic test. Similarly, a test to determine whether an individual has a genetic variant associated with hereditary nonpolyposis colorectal cancer is a genetic test. However, an HIV test, complete blood count, cholesterol test, liver function test, or test for the presence of alcohol or drugs is not a genetic test. Genetic testing requires Prior Authorization. As a Presbyterian Insurance Company Member, you and your enrolled dependents (age 18 and older) have access to a designated list of participating national, regional and local fitness, recreation, and community centers.

Fertility Services. This benefit has one or more exclusions as specified in the Exclusions Section. Male vasectomies are covered except for under high-deductible individual or group health plans until an insured’s deductible has been met. Tubal ligation/sterilization is a covered benefit. This benefit has one or more exclusions as specified in the Exclusions Section. Coverage is provided for diagnosing, monitoring, and controlling of disorders of Genetic Inborn Errors of Metabolism (IEM) where there are standard methods of treatment, when Medically Necessary and subject to the Limitations, Exclusions, and Prior Authorization requirements listed in this Agreement. Coverage for the treatment of genetic inborn errors of metabolism are provided with the same Durational limits, caps, deductibles, coinsurance and copayments as any other illnesses. Medical services provided by licensed Healthcare Professionals, including Practitioners/Providers, dieticians and nutritionists with specific training in managing Members diagnosed with IEM are Covered. Covered Services include: • Nutritional and medical assessment. • Newborn Screening for Metabolic Diseases. • Clinical services. • Biochemical analysis. • Medical supplies. • Prescription Drugs/Medications – refer Refer to Prescription Drugs/Medications Section. • Corrective lenses for conditions related to Genetic Inborn Errors of Metabolism. • Nutritional management. • Special Medical Foods are dietary items that are specially processed and prepared to use in the treatment of Genetic Inborn Errors of Metabolism to compensate for the metabolic abnormality and to maintain adequate nutritional status when we approve the Prior Authorization request and when provided under the on-going direction of a qualified and licensed healthcare Practitioner/Provider team. Special medical foods may be prescribed for other medically necessary conditions. This does not include coverage of nutritional items/food supplements that are available over-the the-counter and/or without prescription. • One pair of standard (non-tinted) eyeglasses (or contact lenses if Medically Necessarymedically necessary) is Covered covered within 12 months after cataract surgery or when related to Genetic Inborn Error of Metabolism. This includes the Eye Refraction examination, lenses and standard frames. Refer to pharmacy section of your Summary of Benefits and Coverage for applicable Cost-Cost Sharing amounts (office visit Copayments, Inpatient Hospital, outpatient facility, Prescription Drug/Medications and other related Deductibles, Coinsurance and/or Copayments).‌‌ Genetic/genomic testing means an analysis of human DNA, RNA, chromosomes, proteins, or metabolites, if the analysis detects genotypes, mutations, or chromosomal changes. However, a genetic test does not include an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition. Genetic testing is not used as a screening test. Accordingly, a test to determine whether an individual has a BRCA1 or BRCA2 variant is a genetic test. Similarly, a test to determine whether an individual has a genetic variant associated with hereditary nonpolyposis colorectal cancer is a genetic test. However, an HIV test, complete blood count, cholesterol test, liver function test, or test for the presence of alcohol or drugs is not a genetic test. Genetic testing requires Prior Authorization.