To Whom It May Concern:

We are/I am considering In Vitro Fertilization. This procedure is needed to attempt pregnancy due to our/my inability to concieve as a result of: (state your reason ie: tubal ligation/disease, vasectomy, ovulatory dysfunction, endometriosis, etc.)

Please provide me with a written response to each question below.

• Will In Vitro Fertilization be a payable procedure under current coverage?
• If yes, is there a limit of any kind? (e.g. dollars spent, attempts performed)
• If no, are any portions of the charges payable, such as prescription (injectable) drugs, office visits, laboratory tests and/or ultrasounds?
• If any of the charges are not payable state the pages in the contract where those charges are specifcally excluded and the date the exclusion was added to the contract. If the charges are not specifically excluded I will assume they are payable.

Thank you. Your anticipated cooperation is greatly appreciated.

Sincerely,