Does Fallon Health cover IVF?
What Fallon Health (Massachusetts) publishes about covering IVF and other fertility treatment, in its own words, with the document each statement is in.
- Documents read · checked 11 h ago
On its Community Care plans, IVF is covered, as Massachusetts' infertility law requires. Fallon's 2026 schedules list IVF, GIFT and ZIFT as covered with a $125 or $250 copayment per procedure, and IUI covered in full, with a referral and prior authorization. Its policy requires infertility (a year of trying at 35 or younger, six months over 35) and ovarian reserve tests in range (FSH 12 or lower, AMH 1.0 or higher). Its MassHealth plan covers only diagnosing and treating the cause.
What Fallon's policy and schedules say
Read on Oct 27, 2026. The words in quotation marks are the source's own.
Community Care plans: IVF covered, $125 to $250 a procedure (Massachusetts law)
“5. Assisted reproductive technologies (ART) for: • In vitro fertilization (IVF-ET) • Gamete intrafallopian transfer (GIFT) • Zygote intrafallopian transfer (ZIFT) $125 copayment per procedure”
“This policy applies to coverage for infertility services. Coverage for infertility services varies by product.”
Community Care plans, 2026
Fallon's commercial plans are Community Care, sold through the Massachusetts Health Connector to individuals, families and employers with under 50 employees. Their 2026 schedules cover IVF, GIFT and ZIFT with a copayment per procedure ($125 on one plan, $250 on its Platinum and Bronze plans, after the deductible on Bronze) and artificial insemination such as IUI in full.
“Fallon Health offers Community Care plans through the Connector to employers with under 50 employees.”
“5. Assisted reproductive technologies (ART) for: • In vitro fertilization (IVF-ET) • Gamete intrafallopian transfer (GIFT) • Zygote intrafallopian transfer (ZIFT) $125 copayment per procedure”
“$250 copayment per procedure”
“$250 copayment per procedure after you meet your deductible”
“4. Artificial insemination, such as intrauterine insemination (IUI) Covered in full”
Who qualifies
Infertility means a year without conceiving at 35 or younger, or six months over 35; without a male partner, the same number of medically supervised donor sperm IUI cycles. IVF is medically necessary for listed conditions such as tubal or male factor infertility. Treatment based on natural aging, or with under a 5% chance of a live birth per cycle, is not covered.
“Infertility is defined as the condition of an individual who is unable to conceive or produce conception during a period of one year if the female is age 35 or younger or during a period of six months if the female is over the age of 35.”
“For biological females without a biological male partner, the same number of cycles of medically supervised donor sperm IUIs must be documented without a conception to meet the same infertility standard.”
“IVF/ZIFT/GIFT is considered to be medically necessary after the member has met the criteria for infertility coverage as defined in this policy for any of the following conditions:”
“Aging is not a medical illness, and infertility treatments based on the effects of natural aging are not covered.”
“No coverage will be provided for infertility services when the chance of achieving a live birth per any infertility treatment cycle started is <5%”
Ovarian reserve limits
Day 3 or Day 10 FSH must be 12.0 mIU/ml or lower and estradiol under 100 pg/ml; any abnormal value, such as AMH under 1.0 ng/ml or an antral follicle count under 7, ends infertility treatment coverage. Members 40 to 43 need a yearly clomiphene challenge test.
“All Day 3 or Day 10 FSH must be ≤12.0 mIU/ml. The Day 3 estradiol should be <100 pg/ml.”
“Any abnormal value ends infertility treatment coverage, such as AMH <1.0 ng/ml or basal AFC <7 or basal FSH >12.0 mIU/ml or estradiol > 100.0.”
“women ≥40 and <44 years without documented premature diminished ovarian reserve, will require a yearly clomiphene citrate challenge test (CCCT)”
Referral and prior authorization
Infertility services need prior authorization, and on Community Care a referral too, unless a Reliant Medical Group specialist treats a member with a Reliant PCP. Certain fertility drugs need prior authorization and have quantity limits, and pharmacy members get infertility drugs only when they meet the policy's criteria.
“Fallon Health requires prior authorization for infertility services.”
“Infertility/assisted reproductive technology (art) services* Referral and prior authorization required (unless provided by a Reliant Medical Group specialist and you have a Reliant Medical Group PCP)”
“Certain fertility medication also requires prior authorization; some may have a quantity limit for each prescription as well.”
“Members who have Pharmacy Benefits will not be approved for infertility drugs unless they meet criteria as defined in this policy.”
Freezing and storage
Freezing and storing sperm, eggs or embryos is covered for up to 24 months during active treatment or before a treatment that may cause infertility, including one IVF cycle with egg or embryo freezing under 44. Elective egg freezing and storage beyond 24 months are excluded.
“Sperm, egg, and/or inseminated egg procurement, assisted hatching, cryopreservation, processing and storage/banking for up to 24 months for plan members in active infertility treatment and when a member has a condition or is undergoing medical treatment that may result in infertility, to the extent that such costs are not covered by the donor’s insurer”
“Where a disease or the necessary treatment of that disease has a likely side effect of loss of fertility, this Plan will provide coverage for a single cycle of IVF with egg or embryo”
“Elective egg freezing for fertility preservation.”
“Storage of cryopreserved sperm, eggs or embryos for more than 24 months.”
Not covered
PGT-A embryo screening (PGD is covered for known carriers of certain genetic disorders), surrogacy and a donor egg with a gestational carrier, and donor eggs for age-related decline. Donor sperm is covered, up to two vials a cycle, when the male partner's semen meets the policy's criteria.
“Preimplantation genetic testing for aneuploidy (PGT-A, previously known as preimplantation genetic screening or PGS)”
“6. ART-related services, including: • Intracytoplasmic sperm injection (ICSI) for the treatment of male factor infertility or when preimplantation genetic diagnosis (PGD) testing is covered • PGD when the partners are known carriers for certain genetic disorders”
“Coverage for services related to achieving pregnancy through a surrogate. Use of donor egg and gestational carrier is not covered, as the female member is not physically treated in this situation and is effectively a surrogate service.”
“Donor eggs/donor embryos for age-related decline in egg quantity or quality, even if the member also has a medical cause of infertility which is normally treated by IVF”
“Donor sperm is covered (up to 2 vials per IVF/IUI cycle) when the biological male partner’s sperm meets the criteria below.”
MassHealth plan
On Fallon's MassHealth ACO plan, only diagnosing and treating the underlying cause of infertility is covered, not IUI or IVF.
“MassHealth covers only the diagnosis and treatment of the underlying cause of infertility. There is no coverage for treatments, such as IUI or IVF services.”
Whether your Fallon Health plan covers IVF
The Fallon Health policy says how it pays for IVF when a plan includes it. Three things decide whether yours does.
- 1.Your employer's choice
Most people with Fallon Health coverage get it through work, and the employer picks the benefits. About 50% of employers with 500 or more workers now cover IVF.
- 2.Your plan type
A fully-insured plan follows the law of the state it is issued in. A self-funded plan, which 67% of covered US workers have, does not: it covers whatever the employer chose.
- 3.Your state's law
Some states require fully-insured plans to cover IVF, some require insurers only to offer it, and most require nothing. Your state's line is below.
What specific employers publish about their fertility benefits, including which insurer or benefit company runs them: companies that cover IVF.
Does Fallon Health cover IVF in Massachusetts?
Massachusetts's insurance law applied to a Fallon Health plan issued there. A state law reaches plans issued in that state, usually your employer's state, not where the clinic is.
Fallon Health in Massachusetts
Often, on fully-insured plans: Massachusetts requires some fully-insured health plans to cover IVF, and that includes Fallon Health plans issued in Massachusetts unless one of the law's limits or exemptions applies. One of the broadest IVF mandates; fully-insured plans must cover it. A self-funded employer plan that Fallon Health only administers is not bound by state law and covers IVF only if the employer chose to. Massachusetts law and clinics
State laws as summarized by RESOLVE Insurance Coverage by State, read Oct 1, 2026.
How to see what your Fallon Health plan covers
A policy or program page is a summary. Your own plan's documents are what it pays by.
- 1Read the infertility and ART lines in your Community Care Schedule of Benefits and the Member Handbook's Description of benefits.
- 2Log on to MyFallon or call Customer Service at the number on your ID card, which also has Fallon's infertility coverage guidelines.
- 3Get a referral and prior authorization before treatment, and have your FSH, estradiol and AMH results ready.
Fallon Health and IVF: common questions
Does Fallon Health cover IVF?
On its Community Care plans, yes: its 2026 schedules cover IVF, GIFT and ZIFT with a $125 or $250 copayment per procedure, with a referral and prior authorization, as Massachusetts law requires. Its MassHealth plan does not cover IVF.
Does Fallon cover IUI?
Yes: artificial insemination such as IUI is covered in full on its 2026 Community Care schedules (after the deductible on Bronze).
Does Fallon have an age or AMH limit for IVF?
No single maximum age, but FSH must be 12.0 or lower and an abnormal value such as AMH under 1.0 ends coverage; treatment based on natural aging is not covered.
Does Fallon cover egg freezing?
Before a treatment that may cause infertility, and during active treatment, with storage up to 24 months. Elective egg freezing is excluded.
- Fallon Community Health Plan, Inc. Community Care Schedule of Benefits C157 (form 24-670-018_C157_0126) (Fallon Health, Plan year 2026)
- Fallon Health Infertility Services Clinical Coverage Criteria (Fallon Health, Effective 09/01/2025)
- Fallon Health employers page (Fallon Health)
- Fallon Community Health Plan, Inc. Platinum Connector Schedule of Benefits (Community Care) (Fallon Health, Plan year 2026)
- Fallon Community Health Plan, Inc. Bronze Connector I Schedule of Benefits (Community Care) (Fallon Health, Plan year 2026)
- Fallon Community Health Plan, Inc. Community Care Amendment 2 (form 24-670-018_A2_0525), in the 2026 amendments file (Fallon Health, Amendment 2, May 2025 form; file live in 2026)