Medication Rider

Your Certificate of Coverage is amended as described • any variations of these procedures, including in this document. This rider becomes a part of your costs associated with collection, washing, Certificate of Coverage and is subject to all provisions preparation or storage of for artificial including donor fees, of your Contract, including any riders. Please see of donor sperm and eggs. your Outline of Coverage for specific details. Note: This exclusion does not apply to the evalua- I. Covered Services tion to determine if and why a couple is infertile. The following exclusion is ADDED: The chapter in your Certificate of Coverage entitled Covered Services is hereby amended by adding the Infertility services. This includes, but is not limited to: following Covered Service if it is not already in your • artificial insemination (intravaginal, Certificate of Coverage. It does not replace any services intracervical, and intrauterine insemination); already included in your Certificate of Coverage. • in vitro fertilization, embryo transplantation and gamete intrafallopian transfer (GIFT); Fertility Medications • zygote intrafallopian transfer (ZIFT); and We Cover up to four months of fertility medications • any variations of these procedures, including per calendar year when you attempt to costs associated with collection, washing, preparation or storage of sperm for conceive through natural means and not by: artificial insemination including donor fees, ƒƒartificial insemination; cryopreservation of donor sperm and eggs. ƒƒin vitro fertilization; Note: This exclusion does not apply ƒ embryo transplantation; to the evaluation to determine if ƒ and why a couple is infertile. ƒƒgamete intrafallopian transfer; ƒƒzygote intrafallopian transfer; or ƒƒany variations of these procedures.

II. General Exclusions Don C. George President and CEO Infertility Treatment The chapter in your Certificate of Coverage entitled “General Exclusions” is hereby amended. The following exclusion is STRICKEN: Infertility services. This includes, but is not limited to: ƒƒall medications for treatment of infertility, including but not limited to Clomid, Clomiphene, Serophene, Bravelle, Gonal-F, Follistim AQ, Novarel, Ovidrel, Pregnyl, Profasi and Repronex when used for treatment of infertility; and ƒƒsurgical, radiological, pathological or laboratory procedures leading to or in connection with (for example): • artificial insemination (intravaginal, intracervical, and intrauterine insemination); • in vitro fertilization, embryo transplantation and gamete intrafallopian transfer (GIFT); • zygote intrafallopian transfer (ZIFT); and

280.327 (01/2019) Blue Cross and Blue Shield of Vermont 1