The program coordinator works with patients to verify which infertility treatments and medications their health insurer will cover and what patients may expect to pay out-of-pocket.
Below is general information about insurance coverage and fertility treatment.
Actual Contract and Summary Plan Description
Insurance policies come in two forms: the actual contract and the summary plan description.
The summary plan description is a brief summary of medical benefits and is usually provided when you enroll in an insurance plan. You will need to request a copy of the actual contract and can obtain this information from the employer who issued the contract or from your insurance company or agent.
The summary plan description provides a general explanation of your plan and benefits. It will let you know whether you are enrolled in HMO, PPO or indemnity coverage. In general, HMOs are the least costly plans and have more limited coverage. However, quite a few HMOs provide at least partial coverage for IUIs or medications. It is important to look carefully at the benefits your employer provides at open enrollment and consider changing companies to get the best benefits for fertility.
If you are able to get a copy of the contract, then the next step is determining how your insurer defines infertility as different insurers have different definitions.
For example, your insurer may consider infertility to be 12 months of attempted conception. However, if you have irregular or absent menstrual cycles, it would not be reasonable to attempt conception for 12 months if you are not ovulating regularly. Instead, you may consider seeking treatment for irregular cycles initially to determine if there are hormonal reasons why menses are not regular.
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Questions to Consider
Below are other insurance questions that you should consider before seeking treatment.
- What type of coverage is listed?
- Which procedures require preauthorization? Does preauthorization need to be done for each cycle of treatment and how long does it take to get?
- Are there restrictions on the type of healthcare provider who can perform infertility services?
- Are there limits to the number of procedures or the maximum dollar limit on benefits? For example, some patients are limited to three treatment cycles of any type, including IVF, compared to the more common limitation of three or six cycles of IUI and one or three cycles of IVF. It is also important to know if the maximum dollar benefit is lifetime or annual. Some policies have limits on the age of the female patient or the number of months of treatment.
- Is there a co-payment for medical services?
- Is there a co-payment for drug coverage?
- Is prior authorization needed for these medications?
- Does my plan cover self-administered subcutaneous (under the skin) or oral medications?
- Are there discounts for mail-order medications?
- Are any of the drugs on the prescription formulary and therefore covered?
- The name of your insurer
- Your policy identification number
- The insurance company patient representative or contact person
- The insurance company phone and fax numbers
- The insurance company e-mail address and Web site
- Group and ID numbers (patient insurance identification number)
- Name of treatment(s) and/or medication(s)
- Reason for needing the procedure/treatment/medication
- Will the treatment/procedure/medication be covered under my current coverage or under my major medical portion?
- If yes, is there any limit of any kind-dollar amount or number of attempts?
- If no, are any portions of the charges covered for prescription medication, laboratory tests or ultrasounds leading up to the intrauterine insemination?
- If none of the charges are payable, please identify the page in my contract where all of the charges are specifically excluded.
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