MMC Benefits Handbook
Family Planning
For questions related to infertility treatment, contact WIN at +1 844 446 2329. A diagnosis of infertility is solely determined by WIN, the Claims Administrator.
WIN infertility medical coverage is available to you and your eligible family members (spouse/domestic partner and children) enrolled in the Plan with a diagnosis of infertility.
Does the Plan cover infertility treatment?
The Plan covers infertility treatments with a benefit cap of $40,000 for infertility-related medical treatment and prescription drug costs through WIN. WIN providers are the exclusive providers and the only providers for infertility-related services and treatment. There is NO out-of-network infertility coverage under the WIN program.
Under the $1,650 Deductible Plan
- 80% for in-network providers after the Plan's deductible has been met. WIN providers are the exclusive providers and the only providers for infertility-related services and treatment. There is NO out-of-network infertility coverage under the WIN program.
Under the $3,300 Deductible Plan
- 70% for in-network providers after the Plan's deductible has been met. WIN providers are the exclusive providers and the only providers for infertility-related services and treatment. There is NO out-of-network infertility coverage under the WIN program.
Covered infertility services include:
- Diagnostic services for fertility not covered by another source.
- Artificial insemination (AI) cycles and timed intercourse (natural cycles, clomid/letrozole cycles).
- The following assisted reproductive treatment cycles and procedures are covered:
- In-Vitro Fertilization (IVF)
- Intracytoplasmic Sperm Injection (ICSI)
- Assisted Hatching
- Oocyte Thaw Cycles (OTC)
- Frozen Embryo Transfer (FET)
- Gamete Intrafallopian Cycle (GIFT)
- Zygote Intrafallopian Transfer (ZIFT)
- Preimplantation Genetic Testing with Embryo Biopsy covered if any of the following criteria is met:
- Recurrent Pregnancy Loss (two or more unexplained clinical pregnancy losses) or previously diagnosed aneuploid pregnancies or births
- Recurrent implantation failure (three or more failed embryo transfers)
- Both parents are carriers of a recessive single gene autosomal mutation
- One parent is a known carrier of a single gene autosomal dominant or X-linked disease
- One parent is a known translocation carrier.
- Cryopreservation of blastocysts(s) and embryo(s) from covered IVF and OTC cycles with storage for up to one (1) year from the date of the initial cryopreservation.
- Oocyte cryopreservation cycles including one year of storage from the initial date of cryopreservation when a medical treatment will directly or indirectly lead to iatrogenic infertility (an impairment of fertility by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes).
- Sperm cryopreservation including one year of storage from the initial date of cryopreservation when a medical treatment will directly or indirectly lead to iatrogenic infertility (an impairment of fertility by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes).
- Pathology and laboratory services related to infertility treatment, including but not limited to:
Infertility treatment is covered when medically necessary (i.e., when a covered member has a diagnosis of infertility). The definition of infertility utilized by WIN is the inclusive definition of infertility adopted by the American Society of Reproductive Medicine (ASRM). Medical necessity and eligibility is solely determined by WIN, the Claims Administrator.
You must obtain preauthorization before receiving infertility treatment.
For information on infertility prescriptions, refer to the "Prescription Drugs – WINFertility ("WIN") – Infertility Prescriptions Only").
What network is utilized for coverage of infertility (medical and pharmacy) treatment?
You must utilize WIN's provider network and pharmacy network for coverage for infertility treatments and services. For information on WIN's pharmacy network, refer to "Prescription Drugs – WINFertility ("WIN") – Infertility Prescriptions Only"). For information on WIN's medical provider network, refer to the question below.
Is there a network of providers for infertility-related treatment?
There is a network of providers focused on infertility using WIN's network. WIN is a specialty fertility network. Providers in the WIN network can be found here: https://managed.winfertility.com/mmc-2 or by downloading the WINFamily app.
Note: Only providers who are part of WIN's network are covered. There is no out-of-network coverage for infertility-related treatments.
Will the lifetime maximum accumulations prior to WIN's implementation be transferred?
Yes, all infertility-related medical and prescription drug accumulations from Aetna and CVS Caremark® will be transferred to WIN for January 1, 2025.
How does the infertility coverage work with WIN?
All infertility coverage (including medical care and prescription drug costs) will be provided exclusively through WIN. WIN features Nurse Care Advocates who will work with you to help you make complex decisions regarding diagnosis and care. They'll provide support, help you navigate the WIN exclusive provider network, and provide other support/educational services.
A diagnosis of infertility is solely determined by WIN, the Claims Administrator.
Cost share (plan deductible and coinsurance) apply to infertility benefits.
There is a combined lifetime maximum of $40,000 per eligible plan participant for eligible medical care and prescription drug expenses related to infertility treatment and related infertility medications.
If you plan to start treatment for infertility, call WIN at +1 844 446 2329, Monday to Friday, 9:00 am to 9:00 pm, ET and speak to a Nurse Care Advocate who will help you find an in-network WIN provider based on your individual treatment needs and goals. WIN can also help check and confirm if your current preferred provider is participating in the WIN network.
You can also download the WINFamily App on the App store or Google Play using app code: MMC18 to schedule an appointment with a Nurse Care Advocate or go to https://managed.winfertility.com/mmc-2.
All infertility services and treatments are subject to a confirmation of a diagnosis of infertility by WIN and pre-authorization requirements. Failure to obtain authorization of services will result in a claims denial of benefits.
How do I contact the WIN Claims Administrator?
You can contact WIN for infertility claims at +1 844 446 2329, Monday to Friday, from 9:00 am to 9:00 pm Eastern Time and ask to speak to with a WIN Nurse Care Advocate. Alternatively, you can also download the WIN app and schedule a Nurse Care Advocate consultation in the Find Care section.
How do I file a claim for benefits for infertility treatment with WIN?
Your WIN provider files claims on your behalf. If you have any questions, please contact WIN, the claims administrator, at +1 844 446 2329 Monday through Friday from 9:00 am to 9:00 pm Eastern Time.
Are contraceptive devices covered under the Plan?
The Plan covers contraceptive devices under the medical plan at:
Under the $1,650 Deductible Plan
- 100% for in-network providers (no deductible) and 60% of reasonable and customary charges for out-of-network providers after the Plan's deductible has been met.
Under the $3,300 Deductible Plan
- 100% for in-network providers (no deductible) and 50% of reasonable and customary charges for out-of-network providers after the Plan's deductible has been met.
Certain contraceptives are covered under the prescription drug plan including oral and injectable contraceptives as well as contraceptive devices.
To check drug coverage, visit www.caremark.com.
Does the Plan cover vasectomy?
The Plan covers vasectomies at:
Under the $1,650 Deductible Plan
- 80% for in-network providers and 60% of reasonable and customary charges for out-of-network providers after the Plan's deductible has been met.
Under the $3,300 Deductible Plan
- 70% for in-network providers and 50% of reasonable and customary charges for out-of-network providers after the Plan's deductible has been met.
You must obtain preauthorization before you are admitted to the hospital.
Vasectomy reversals are not covered under the Plan.
Does the Plan cover tubal ligation?
The Plan covers in-patient and outpatient tubal ligation at:
Under the $1,650 Deductible Plan
- 100% for in-network providers with no deductible and 60% of reasonable and customary charges for out-of-network providers after the Plan's deductible has been met.
Under the $3,300 Deductible Plan
- 100% for in-network providers with no deductible and 50% of reasonable and customary charges for out-of-network providers after the Plan's deductible has been met.
You must obtain preauthorization before you are admitted to the hospital.
Tubal ligation reversals are not covered.