Situation

CHOICE PLUS

NETWORK

CHOICE PLUS

NON-NETWORK

Birth Control Pills

See Prescription Drug Section for pharmacy benefits.

See Prescription Drug Section for pharmacy benefits.

ParentSteps(^SM)

Not Applicable

Not Applicable

Reproductive Resource Services Program (RRS)

Not Applicable

Not Applicable

Infertility

Covered Health Services for infertility services and associated expenses including:

●  Diagnosis and treatment of an underlying medical condition that causes infertility when provided by or under the direction of a Physician.

The following services are not covered:

●  Health services and

associated expenses for infertility treatments including:

●  In vitro fertilization

(IVF);

●  Gamete intrafallopian

transfer (GIFT);

●  Zygote intrafallopian

transfer (ZIFT);

●  Artificial insemination;

●  Embryo transport; and

●  Donor ovum and

semen and related costs including collection, preparation and storage of.

Physician’s Office Services

$35 copay per visit then 90% of eligible expenses.

Outpatient Services received at a Hospital or Alternate Facility

90% of eligible expenses.

Any combination of Network and Non-Network Benefits for infertility services is limited to a lifetime maximum of $1,500 per Covered Person.

80% of eligible expenses after satisfying $300 deductible.

Any combination of Network and Non-Network Benefits for infertility services is limited to a lifetime maximum of $1,500 per Covered Person.

Reproduction

Same as:

●  Physician's Office

Services

●  Professional Fees

●  Hospital-Inpatient Stay

●  Outpatient Diagnostic

and Therapeutic Services.

Applicable services:

●  Voluntary sterilization.

●  Surgical, non-surgical or

drug induced Pregnancy termination.

●  Health services and

associated expenses for elective abortion.  Dependents not covered.

●  Contraceptive supplies and services.

The following services are not covered:

●  Surrogate parenting.

●  The reversal of voluntary

sterilization.

●  Artificial reproductive

treatments done for genetic or eugenic (selective breeding) purposes.

Same as:

●  Physician's Office

Services

●  Professional Fees

●  Hospital-Inpatient Stay

●  Outpatient Diagnostic

and Therapeutic Services.

Applicable services:

●  Voluntary sterilization.

●  Surgical, non-surgical or

drug induced Pregnancy termination.

●  Health services and

associated expenses for elective abortion.  Dependents not covered.

●  Contraceptive supplies and services.

The following services are not covered:

●  Surrogate parenting.

●  The reversal of voluntary

sterilization.

●  Artificial reproductive

treatments done for genetic or eugenic (selective breeding) purposes.

Tubal Ligation

Physician’s Office Services

$35 copay per visit then 90% of eligible expenses.

Outpatient Services received at a Hospital or Alternate Facility

90% of eligible expenses.

Reversals are not covered.

80% of eligible expenses after satisfying $300 deductible.

Reversals are not covered.

Vasectomy

Physician’s Office Services

$35 copay per visit then 90% of eligible expenses.

Outpatient Services received at a Hospital or Alternate Facility

90% of eligible expenses.

Reversals are not covered.

80% of eligible expenses after satisfying $300 deductible.

Reversals are not covered.