Beginning your fertility journey can be incredibly overwhelming. It can feel like you need to become an overnight expert in human anatomy, the menstrual cycle, injectable medications, and worst of all, health insurance.
To give you the most comprehensive and accurate information about this complex topic, we worked with experts from Alto Pharmacy to address common questions about insurance coverage for fertility treatments and medications.
1. How can I find out if my insurance plan covers fertility medications?
Insurance coverage of fertility medications can vary widely from one plan to another and from state to state. The best way to determine what your plan covers is to contact your insurance provider for an in-depth explanation of your benefits.
Here are a few tips for the call:
Have your insurance card available to reference - you will be asked to confirm your identity and provide membership information during the call
Be prepared to share information about your current treatment plan and cycle type, as well as prior treatment, if applicable
If you already have the details of your treatment plan, have a list of your medications available to reference
Call the member services number on the back of your insurance card to start this conversation. Here are a few questions you can ask:
Eligibility and Coverage Details:
What specific fertility treatments and services are covered under my policy (e.g., IVF, IUI, egg freezing)?
Are there specific eligibility criteria or requirements to access fertility coverage? (e.g., some insurances require a few rounds of IUI in order to cover IVF)
What if my cycle gets canceled?
Diagnostic Testing:
Are fertility-related diagnostic tests, such as hormone levels or semen analysis, covered?
Costs and Limits:
Is there a cap on the number of cycles or treatments covered annually or in total?
Are there out-of-pocket costs like copays or co-insurance for fertility treatments?
What is the deductible amount that applies to fertility coverage?
Prescription Medication:
Are fertility medications such as injectable ovarian stimulation medications or oral ovulation induction medications covered?
Are there any specific conditions to be met before medications are covered?
Providers and Network:
Are there specific fertility clinics or specialists that I must use for coverage to apply?
Will I be reimbursed if I choose an out-of-network fertility clinic or provider?
Prior Authorization:
Do I need prior authorization for fertility medications or pre-approval before beginning fertility treatments?
What documentation or process is required for approval?
Additional Therapies and Support:
Are additional supportive treatments, such as acupuncture, covered?
Is counseling or emotional support included as part of the coverage?
Appeals and Exceptions:
How can I appeal a denial of coverage or request an exception to existing guidelines?
Maternity and Post-Treatment:
What prenatal and maternity services are included if the fertility treatments are successful
Are post-treatment services or support, like embryo or egg storage, covered?
2. How can I maximize my fertility insurance benefits?
If you have limited coverage of fertility treatment, there will likely be ways to maximize it and reduce unnecessary costs. Try exploring these options as a starting point:
Check if the co-insurance — the percentage you pay after you meet your deductible — is lower if you see an in-network doctor or clinic.
Check what your insurance coverage would be if an in-network OB/GYN performs part or all of the diagnosis tests.
If you have pre-tax health savings account (HSA) or flexible spending account (FSA) dollars available through your benefits, consider using them to pay for all or part of your fertility treatment.
There may be additional ways to reduce treatment costs, including manufacturer assistance programs and scholarship opportunities, which we cover in more detail in another article in this series, Three Ways To Make Fertility Treatment More Affordable.
3. What’s the difference between medical and prescription coverage?
Health insurance includes medical and prescription coverage. Medical coverage typically includes doctor’s appointments, tests, and procedures, while prescription coverage includes coverage for medications.
Due to the specialized nature of fertility treatment, some insurance plans cover fertility prescriptions under medical benefits (as opposed to prescription coverage). This may affect the total cost of your medications, so confirm whether your prescriptions will be covered under your medical or prescription coverage when you begin considering your financial options.
4. What factors should I weigh when deciding between using medical benefits or paying out of pocket for fertility medications?
There are two key factors to account for when deciding whether to use medical insurance or pay out of pocket:
What is your lifetime or annual maximum?
Is it possible you will pursue further treatment after this cycle?
Here’s why: If your medications are billed to your medical insurance, this may limit future treatment options depending on your lifetime or annual maximum.
For example, if your lifetime maximum is $20,000, and $10,000 is billed to medical treatment for prescriptions, this leaves just $10,000 under your medical benefits. In this case, it could be beneficial to pay for your medications out of pocket (which might also be cheaper than those billed via insurance) and reserve remaining benefits for more expensive future treatments. Discuss options with your provider and your clinic’s billing team.
5. If my insurance covers fertility prescriptions under medical benefits, is that always the most cost-effective way to pay for them?
Not always. If your insurance covers fertility prescriptions under medical benefits, it may be more cost effective to pay for some or all of your prescriptions out of pocket than to use your medical insurance coverage.
Note: The amount billed to your medical insurance for fertility medications is often more than what you would be charged for the same medication out of pocket, and this can affect your ability to maximize the value of your insurance coverage, as explained in Question 4 above.
So you can explore every option, always ask for an out of pocket quote for your medications. You can ask your provider for pharmacy recommendations — some even offer discounted pricing. You can also get a quote from an online pharmacy such as Alto Pharmacy here.
6. What factors influence the amount I will be billed by my insurance for fertility treatments?
If you have some insurance coverage for fertility treatment, the amount you will pay depends on a few primary factors:
The coverage details of your specific health insurance policy, including your deductible and co-insurance*, what portions of fertility treatment your plan covers, and if there’s a cap on fertility coverage
Whether a provider is in-network with your insurance
Whether a pharmacy is in-network with your insurance
Any diagnoses you’ve received that are related to infertility
Any fertility treatments you’ve previously done and their results
*Co-insurance is the amount you may be required to pay as your share of the cost for services after any deductibles. A deductible is the amount you owe for healthcare services before your health insurance begins to pay.
Understanding your insurance coverage can be an incredibly complex process. The best way to determine what will be the most cost effective for you is to do your research. Minimizing your out-of-pocket costs requires you to determine what benefits you have and when and how you want to use them. During this information-gathering process, your goal is to determine which clinics, treatments, and medications will get you the most bang for your buck through your insurance coverage. Depending on your individual insurance details, it may make more sense to pay for your medications out of pocket and use your benefits later.
For more information on fertility care and affordability, check out Alto Pharmacy’s affordability page!