Every applicable policy or certificate must provide benefits for in vitro fertilization procedures when:

1. (1) The patient is the policyholder or the spouse of the policyholder/certificate holder and a covered dependent under that policy or certificate;
2. (2) The patient's oocytes are fertilized with the sperm of the patient's spouse;

3. (3) Either:

   1. (A) The patient and the patient's spouse have a history of unexplained infertility of at least two (2) years' duration; or

   2. (B) The infertility is associated with one (1) or more of the following medical conditions:

      1. (i) Endometriosis;
      2. (ii) Exposure in utero to diethylstilbestrol, commonly known as DES;
      3. (iii) Blockage of or removal of one (1) or both fallopian tubes (lateral or bilateral salpingectomy) not a result of voluntary sterilization; or
      4. (iv) Abnormal male factors contributing to the infertility;

4. (4)

   1. (A) The in vitro fertilization procedures are performed at a medical facility licensed or certified by the Department of Health.
   2. (B) Those performed at a facility certified by the Department of Health conform to the American College of Obstetricians and Gynecologists' guidelines for in vitro fertilization clinics, or those performed at a facility certified by the Department of Health meet the American Fertility Society's minimal standards for programs of in vitro fertilization; and
5. (5) The patient has been unable to obtain successful pregnancy through any less costly applicable infertility treatment for which coverage is available under the policy.