How to understand your fertility medication and treatment insurance benefits so you don’t get a costly surprise

With more and more employers offering fertility related benefits to their employees, it is very important that you as a prospective fertility patient “peel the onion” with your insurance carrier to determine what health insurance benefits you DO and DON’T have.

Reproductive Science Center will also do a complimentary health benefits check and obtain authorization from your insurance carrier. But the ultimate responsibility rests with you the patient.

The high cost of misunderstanding fertility health insurance benefits

Recently we have had multiple patients from different employers and different insurance carriers come to RSC with a $15,000 to $20,000 lifetime maximum for fertility treatment. This equates to about one IVF (in vitro fertilization) cycle NOT including medication expenses, which can cost an additional $3,000-$6,000.

Some of these patients misunderstood their fertility health insurance benefit and thought they had two separate buckets of money: one for their treatment and one for their medications. This was NOT the case.

The patients decided – based upon what they were told – to use their benefit for the medications, thinking they would have another $15,000-20,000 for treatment. In fact, there was no medication bucket, and they then were charged $12,000 or more for the medications, leaving little if any benefit for the treatment provided by RSC.

The interesting thing to note is that if they would have paid cash for their medications, they would have paid about $3,000-6,000 – and still had the $15,000-20,000 benefit left for an IVF cycle.

Why is the medication higher when you use your health insurance benefit? We believe it’s because the insurance companies are paying the claims based on the drug manufacturer’s price provided by the pharmacy. When you pay cash, you receive a pharmacy and clinic discount.

So, what should you do?

Obtain in writing from your insurance carrier the benefit you have for fertility treatment. Specifically ask about medications and how they will be processed, and the impact on your total benefit.

Decide how you may want to spend the benefit you do have. If medications are not covered in a separate bucket, you will most likely be better off paying cash and using the benefit you do have toward your treatment.

Ask a lot of questions and don’t assume anything.

Peeling the onion beforehand will lead to less frustration on the backend and allow you to concentrate on pursuing your dreams of family.

– JoAnne Brian, Director of Practice Development