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<br />m VITRO FERTI:LIZAnON RIDER <br />FOR USE ONLY WITH 'ŒXAS HEALTH PIANS, mc. <br />GROUP MAS'ŒR CCNTBACT/mmOI.I.EES CE:B.TIFICATE OF COVERAGE <br /> <br />In coosideration of timely payment of health services fees, it is agreed that <br />the benefits of this Rider together with thé te.rms and conditions hereof shall <br />be added to the Schedule of Benefits in accordance with the te.rms and <br />conditions of the Texas Health Plan's Group Master Contract/Enrollees <br />Certificate of Coverage in conjunction with this Rider as issued. <br /> <br />PART I - DEFINITIONS <br /> <br />Benefits for in vitro fertilization provided through this Rider are subject to <br />the provisions of the Group Master Contract/Enrollees Certificate of Coverage <br />to which this Rider is a part. <br /> <br />"In vitro fertilization" means the process of uniting of ova and sperm by <br />artificial means outside of the human body for the production of a fertile <br />ovum. <br /> <br />PART II - BENEFITS <br /> <br />For the purpose of this Rider, benefits for the treatment of infertility by in <br />vitro fertilization will be provided to the same extent as the benefits <br />provided for outpatient pregnancy related procedures under this Group Master <br />Contract/Enrollees Certificate of Coverage, when authorized in advance by the <br />Health plan and recommended by a THP Participating Primary Care Physician. <br />Such benefits will be provided subject to the following conditions: <br /> <br />( 1) <br /> <br />the patient for the in vitro fertilization procedures <br />Person; <br /> <br />is a Covered <br /> <br />(2) <br /> <br />the fertilization or attempt at fertilization of the patient's <br />oocytes is made only with. the patient's spouse I s sperm; <br /> <br />(3) <br /> <br />the patient and the patient's spouse have a history of infertility <br />of at least five continuous years' duration or the infertility is <br />associated with one or more of the following conditions: <br /> <br />(a) <br />(b) <br />(c) <br /> <br />endometriosis; <br />exposure in utero to diethylstilbestrol (DES); <br />blockage of or surgical removal of one or both <br />tubes; or <br />oligospennia; and <br /> <br />fallopian <br /> <br />(d) <br /> <br />(4) <br /> <br />the patient bas been unable to attain a successful pregnancy <br />through any less costly applicable infertility treatments for which <br />coverage is available under the plan; and <br /> <br />THPINVITRO <br /> <br />1 <br />