CurrentFidelis CarePolicy N/A

Family Planning and Infertility Services (Ovulation Induction Coverage Criteria)

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

3ultrasounds 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:

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

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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

Combined lifetime limitMaximum 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

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.

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.

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.

OpenPayer

Family Planning and Infertility Services (Ovulation Induction Coverage Criteria)

Coverage Criteria — Ovulation Induction & Related Services

Coding, Limits, and Related Quantities

Provider Actions, Prior Authorization & Billing

Background

Definitions