Figuring out how to pay for your fertility treatment can be daunting. Considerations include the type of treatment (e.g., IVF is more expensive than IUI) and required medications. To simplify your decision between paying out of pocket or using fertility benefits, we consulted Alto Pharmacy for essential questions to guide your payment strategy.
The first thing to consider is exactly how much each treatment will cost. Knowing the average cash price for your treatment type can help you decide how to cover the cost.
Questions to Ask Your Insurance Company
The best way to start gathering information is by calling the member services department on the back of your insurance card. Here’s what to ask:
Do my prescription benefits cover fertility medications, including self-injectable medications?
If not, do I have coverage for medications under my medical benefits, and how can I get my prescriptions filled?
Many fertility medications are considered specialty medications. If available, coverage may be included under the medical benefit, which is separate from the prescription coverage you may have for other prescriptions. Only select pharmacies are able to bill medical benefits.
There are many factors to consider if you choose to fill prescriptions under your medical benefits, including annual or lifetime maximums, cost, and future treatment options.
Do I have an annual or lifetime dollar limit for fertility benefits?
How much has been used on my medical benefit?
How much has been used from my prescription benefits?
Do I have a deductible?
It is important to understand the maximums of your coverage and how much you have used in order to inform your decision of whether or not to use your benefits for a given treatment. For example, the out-of-pocket costs for medications might be lower than what would be billed and applied to your maximum.
If your fertility benefit is combined under your medical coverage, reserving coverage for medical procedures can reduce your overall out-of-pocket expenses and allow for future treatment options.
Are there any limitations for coverage (e.g., diagnosis, treatment type, age, total dollars, or number of cycles)?
Is this limit for medications only or does this include medical services like clinic visits, labs, and procedures?
For my specific treatment plan are there limitations? [reference your treatment plan]
Are there requirements to have tried other treatment methods first?
Which of my fertility medications, if any, require a Prior Authorization?
Are there any preferred medications I should use?
What is my copay per medication? Is this applied to my deductible?
Some plans require documentation of previous unsuccessful treatment methods prior to covering specific procedures and associated medications. For example, certain plans require that you have undergone three IUI cycles without success before covering an IVF cycle.
Do I have to use a specific specialty pharmacy for my fertility medications to be covered? Is there a limit to how many prescriptions I can fill at a retail pharmacy?
Some insurance plans require specialty medications to be filled at a specific pharmacy. This may be true whether you are filling through your prescription or medical benefits.
If your insurance requires you to fill with their specialty pharmacy, we recommend getting a quote from Alto Pharmacy or another pharmacy to compare the out-of-pocket costs.
The best way to get the information you need is by asking the right questions. Start by discussing these questions with your insurance provider so you can make the most educated decisions when planning for your treatment and medications.
Want more information about fertility treatments and insurance coverage? Check out the next article in the series with Alto Pharmacy, Top 6 Questions About Fertility Treatment and Insurance