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    v1.0.28
    OpenPayerPolicy UpdatesReproductive Health & FertilityFidelis Care Ovulation Induction Coverage Update |…
    Ask Trek AI about this page
    CurrentFidelis CarePolicy N/A

    Family Planning and Infertility Services (Ovulation Induction Coverage Criteria)

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    Defines Fidelis Care coverage for family planning and certain infertility (ovulation induction) services for NYS Medicaid members, including pharmacy prior authorization routing to NYRx; affects members and participating providers.

    Policy Summary
    PayerFidelis Care
    PolicyFamily Planning and Infertility Services (Ovulation Induction Coverage)
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionObtain prior authorization through NYRx/Magellan for non‑preferred pharmacy drugs by calling 1-877-309-9493 and bill services with the specified infertility diagnosis codes.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    3medication cycles limit
    10pelvis ultrasound lifetime
    3

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    ultrasounds per cycle

    Coverage Criteria — Ovulation Induction & Related Services

    Medically necessary ovulation induction and related infertility services

    Covered when ALL of the following are met:

    Intent and diagnosis: Services performed solely for the intent to establish pregnancy and billed with one of the infertility diagnosis codes E22.1, E28–E28.x, E23.0, L68.0, N97.0, or Z31.41.
    Definition of infertility: Infertility defined as failure to establish clinical pregnancy after 12 months (ages 21–34) or 6 months (ages 35–44).
    Covered services (examples): Includes ovulation enhancing drugs, related medical services, related lab services, office visits, hysterosalpingograms, pelvis ultrasounds, and blood testing to diagnose or monitor anovulation/ovulation induction.
    Medication limits: FDA-approved medications (clomiphene, bromocriptine, letrozole, tamoxifen) covered as a group with a benefit limit of 3 cycles of treatment per lifetime for non-Medicaid Managed Care and HARP plans.3 cycles per lifetime
    Ultrasound limits: Pelvis ultrasounds limited to 3 per cycle with a combined lifetime limit of 10.3 per cycle; 10 lifetime

    The policy's medication cycle limit applies specifically to non‑Medicaid Managed Care and HARP plans. For these plan types, the policy groups the FDA‑approved ovulation induction medications (clomiphene, bromocriptine, letrozole, tamoxifen) and imposes a benefit limit of 3 cycles of treatment per lifetime. Coverage and limits may vary for other plan types; providers should verify member plan benefits when counseling or authorizing therapy.

    Coding, Limits, and Related Quantities

    Covered infertility diagnosis codes (required for ovulation induction coverage)ICD-10Covered
    E22.1
    E28
    E28.x
    E23.0
    L68.0
    N97.0
    Z31.41
    Medication cycles limit — ovulation induction agents
    Covered agentsClomiphene, bromocriptine, letrozole, tamoxifen (FDA‑approved)
    Benefit limit3 cycles of treatment per lifetime (group limit, not per individual agent)
    Applicable plansNon‑Medicaid Managed Care and HARP plans
    Coverage conditionMedications covered as part of ovulation induction when performed solely to establish pregnancy and billed with an infertility diagnosis code
    Pelvis ultrasound limits
    Per‑cycle limitUp to 3 pelvis ultrasounds per treatment cycle

    Provider Actions, Prior Authorization & Billing

    Prior Authorization

    Pharmacy prior authorization (NYRx / Magellan)

    Pharmacy drugs for NYS Medicaid Managed Care members (including HARP) are administered through NYRx (Magellan). Drugs that are not on the NYRx preferred drug list require prior authorization from Magellan. Providers must contact Magellan for prior authorizations, clinical questions, or PDP issues at 1-877-309-9493.

    • Effective April 1, 2023 NYRx (Magellan) administers pharmacy benefits for NYS Medicaid Managed Care members.
    • Prior authorization is required for certain drugs not on the NYRx preferred drug list; see NYRx PDL and PA list: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf
    • For PA or clinical questions, call Magellan at 1-877-309-9493.
    Note

    Supplemental provider actions

    When ordering fertility-related drugs, ensure prescriptions and claims reflect the infertility treatment intent and are consistent with covered indications. If a drug requires PA under NYRx, submit PA to Magellan per NYS Medicaid procedures rather than to Fidelis Care.

    Background

    Infertility for the purposes of this policy refers to the inability to establish a clinical pregnancy. The policy defines onset timelines that determine clinical eligibility: failure to achieve pregnancy after 12 months of regular, unprotected intercourse for individuals aged 21–34, or after 6 months for individuals aged 35–44. Ovulation enhancement and related medical and laboratory services are covered when performed solely with the intent to establish pregnancy and billed with an applicable infertility diagnosis code.

    Covered services for females include ovulation‑enhancing FDA‑approved medications (see plan‑specific limits), office visits, hysterosalpingograms, pelvis ultrasounds, and blood testing to diagnose or monitor anovulation or ovulation induction. Pelvis ultrasounds are limited to 3 per cycle with a combined lifetime limit of 10. FDA‑approved medications (clomiphene, bromocriptine, letrozole, tamoxifen) are covered as a group with a benefit limit of 3 cycles per lifetime for non‑Medicaid Managed Care and HARP plans.

    Definitions

    Definition of Infertility
    Definition (ages 21–34)Failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse
    Definition (ages 35–44)Failure to establish a clinical pregnancy after 6 months of regular, unprotected sexual intercourse
    Clinical implicationDefines eligibility for infertility services (ovulation enhancing drugs, related medical and lab services) when intent is to establish pregnancy
    Policy Summary
    PayerFidelis Care
    PolicyFamily Planning and Infertility Services (Ovulation Induction Coverage)
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionObtain prior authorization through NYRx/Magellan for non‑preferred pharmacy drugs by calling 1-877-309-9493 and bill services with the specified infertility diagnosis codes.
    SourceLink
    On This Page
    Coverage Criteria — Ovulation Induction & Related ServicesCoding, Limits, and Related QuantitiesProvider Actions, Prior Authorization & BillingBackgroundDefinitions
    Combined lifetime limit
    Maximum of 10 pelvis ultrasounds over the member's lifetime
    Service contextUltrasounds covered when performed solely to establish pregnancy as part of infertility treatment
    Patient populationFemales receiving ovulation induction or evaluation for anovulation/PCOS
    • Prescribe and document drugs for the sole intent to establish pregnancy when billing as infertility treatment.
    • Submit prior authorizations for non-preferred drugs through Magellan/NYRx, not through Fidelis Care.
    • Reference the NYRx preferred drug list before initiating therapy to avoid delays.
    Billing Rule

    Billing and documentation requirements for infertility services

    Bill infertility-related services and medications with the appropriate infertility diagnosis codes and include documentation that the service/medication was performed or prescribed solely with the intent to establish pregnancy. Maintain supporting clinical records and related laboratory results.

    • Use infertility diagnosis codes: E22.1, E28 (and subcodes), E23.0, L68.0, N97.0, or Z31.41 when billing ovulation induction and related services.
    • Include clinical documentation demonstrating infertility (timeframe criteria: failure to conceive after 12 months for ages 21–34, or after 6 months for ages 35–44) and that treatment intent was to establish pregnancy.
    • Related laboratory services should be billed with accompanying infertility diagnosis codes and retained in the medical record for review.
    Prior Authorization

    Pharmacy prior authorization routing and requirements

    Pharmacy prior authorization is required for medications not listed on the NYRx preferred drug list; these PAs must be obtained from Magellan. Do not route NYRx drug PAs through Fidelis Care. Check the NYRx PDL before prescribing to determine PA status.

    • NYRx PDL and PA list: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf
    • Magellan prior authorization & clinical support: 1-877-309-9493
    • Pharmacy will bill Medicaid directly for NYRx-covered drugs at retail pharmacies.