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Newbie - Insurance questions!

Insurance IVF IUI

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#1 MJMacD

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Posted 24 April 2014 - 08:59 AM

Hey everyone!

 

I'm new to this forum/site. My husband and I have been TTC for ~4 years now - I'm 30, he's 33, and we're both healthy, active people, experiencing unexplained infertility (I did get pregnant once, but had a missed miscarriage at around 8 weeks). In our second meeting with our RE here in Halifax, she suggested we look into either IUI or IVF as the next step, so we've got a lot of research to do!

 

I'd welcome any feedback related to IUI vs. IVF, but that's not my primary reason for posting here today (IUI vs IVF will really be a personal choice depending on our preferred level of control, spending, invasiveness, etc... but please, provide feedback/advice if you've got it!).

 

My main question relates to health insurance. My husband has insurance through his Union, but it doesn't cover any fertility drugs/treatment, and he has no option to increase coverage under his plan. I work for a tiny company that doesn't provide insurance, so I'm stuck looking at options for individual plans. In my research so far, I've found that many companies won't cover pre-existing conditions - which is fine for us, because our RE has said that she can't give us an infertility diagnosis, because we fall into the 'unexplained infertility' bubble. So that's fine - no pre-existing condition. BUT I've also seen some insurance providers state that they'll only cover procedures/treatments deemed 'medically necessary' - so who makes that judgement call? IVF in my case isn't medically necessary, unless I want to risk trying for another 4 years before I conceive! Other plans are very light on details, only informing you what coverage you would qualify for after you've bought the policy (how crooked does that sound??).

 

So I don't know what to do - anyone else have good advice for insurance policies that help cover some of this cost for unexplained infertility?? I'm still not convinced whether I'm going to do IUI or IVF, but the level of insurance coverage Is absolutely a big part of the decision making process and I'm finding I'm getting very vague answers from providers! 

 

Wow this is overwhelming. So nice to be able to discuss this with all of you!



#2 MeAgain

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Posted 24 April 2014 - 12:39 PM

Our insurance (Dejardains) covers NOTHING...
Me: 39. DH 43 TTC:18 yrs DX: stage 4 endo @ 20 yrs old.FSH- 10-12DH - fine 7 corrective surgeries for endo & blocked tubes open 5 ectopics (natural) (cilia in tubes do not work) IVF #1 ... 2 Grade C 8cell - one healthy baby boy!! 2 frozen 4cell and 6cell- Grade BEctopic (natural)2004 - 8 weeks pg - tube exploded - internal bleeding - surgery - other tube closed Feb 2012 - FET - no transfer IVF# 2 (OFC) March 15 2013- 300iu, cetrotide, hcgONE mature follicle - no fertilization.

July 2013 - EPP - BFN
November - 2013 - EPP - One follicle, one egg, natural fertilization = BFP!!

#3 CdnHockeyGal

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Posted 24 April 2014 - 01:24 PM

Hi MJMacD!  Group insurance (i.e. through your employer or union) only covers IVF if it's specifically designed to.  As an example my group benefits are with GWL and they do happen to cover fertility drugs with no life time maximums...but...the office down the hall might have GWL and have excluded fertility drugs from their plan design coverage...or offer them and have a lifetime max of $5000.  Some group programs with Manu & Sun may offer coverage as well...but again...only generally if they have been designed to do so.  I have never seen a benefits program that offers coverage for infertility treatment.

 

I'm not aware of any personally owned plans that offer fertility drug cost (prohibitive cost).  The occasional IF drug may be covered under group if it has another use or it's usage in fertility is "off-label"...Letrozole is not designed for fertility but can be used...so...it's covered...Lupron can be used to treat endo...so...it's likely going to be covered (call and check first).

 

If your group benefits program covers the provincial formulary (as most do) it is possible to have a drug that's not covered get approved under an "exceptional status"...more commonly referred to as E2 or E3 drugs.  Your MD would have to fill out a form which you would submit to your group insurer.  Again...unfortunately highly unlikely this would work for the big cost fertility drugs.

 

I'm sorry not to be able to provide you with the answers you were hoping for...but...they are accurate.  :(

 

Good luck with your journey!


  • gibasgirl and MJMacD like this
It was long, awful & hard. We got very lucky and didn't run out of both emotional and financial resources. We saw some of the most beautiful of people in our lowest moments. Baby Girl arrived Apr 10/2018

#4 MJMacD

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Posted 24 April 2014 - 01:37 PM

That's ok that it's not necessarily what I want to hear. I don't want to go into this expecting to be covered and find out after I've purchased a plan that it's not covered - all information is helpful - Much appreciated!


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#5 Watermelon

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Posted 24 April 2014 - 03:36 PM

I believe there are a couple of plans that do cover infertility drugs that you can purchase privately. The catch, as you have mentioned, is that they will not cover pre-existing conditions. Where this gets really nasty is that even though you have not been given a diagnosis the mere fact that you have had infertility investigations done (an HSG for example or an RE consult) means that you have already started down the infertility road and may signal to the insurance company that you may have a problem (and thus at high risk of costing them more money than they will make from your premiums) :(

I am relaying this second hand from what I have learned from others on this board, so hopefully someone with first hand experience will confirm. Best advice is to read the fine print of the policy you are considering carefully and, if in doubt, inquire whether the investigations you have had done to date exclude you.

Best of luck.
  • gibasgirl likes this

Me -29 31- unexplained poor egg quality. I was told I had endometriomas.....but repeat ultrasounds at other clinics have said no sign of endometriomas. Maybe PCOS-like ovaries, but no PCOS - AMH, AFC are great. No one can explain why my eggs are so poor sad.png

DH 30 - severe teratospermia, count and motility are excellent.

May 2014 - 2.5mg femara - BFN (ovulated night before)

June 2014 - IUI with 5mg femara - BFN (ovulated night before)

August 2014 - IVF with ICSI - Antagonist protocol, 150Bravelle, 75 menopur, stimmed 8 days

- 19 follicles (all 15-22mm at trigger), 12 eggs retrieved, 7 mature,, 5 fertilized with ICSIsad.png

- only 7 mature eggs with an estrogen of 20000?! wtf?! Sigh...Freeze All

-only one BB Blast made it. Freeze "all" became "freeze one". All others arrested between day 3 and 4 sad.png

January 2015 - FET of lone embryo - c'mon little figher

- BFP!!! Beta 1 475 at 10dp5dt , Beta 2 - 1495 at 12dp5dt

Baby boy born Sept 28/15


#6 CdnHockeyGal

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Posted 24 April 2014 - 04:43 PM

Watermelon is correct...because the conversations have already started...it's a pre-existing condition...even if you have suspicions you have a condition and haven't yet been investigated for it...still considered a pre-ex.


  • gibasgirl likes this
It was long, awful & hard. We got very lucky and didn't run out of both emotional and financial resources. We saw some of the most beautiful of people in our lowest moments. Baby Girl arrived Apr 10/2018

#7 MJMacD

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Posted 27 April 2014 - 06:19 PM

Much appreciated ladies. This insurance world is so foreign to me - it's hard to wrap your head around the fact that I could be buying something without knowing what I'm getting for my money - and the idea that simply seeing an RE could result in an exclusion on the basis of a pre-existing condition. Ridiculous! Luckily, our clinic is hosting an IVF info night tomorrow, so maybe they can give some pointers on how people in my situation have received coverage in the past. All is good - we're not going to let insurance get in the way of us starting a family!



#8 JacMac

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Posted 27 April 2014 - 07:31 PM

Realistically unless they've had coverage through work mist people have to pay for IVF out of pocket.
Me - now 36 Him - 37
Trying to conceive since our wedding day May 25, 2008.
Started Clomid Jan-April 2012.
Referred to RFP June 2012.
First consult at RFP November 2012.
First IVF cycle on antagonist protocol (GonalF, Luveris) January 2013.
Transferred two day-3 embryos, had severe OHSS, lost one twin between 7-13 weeks but was expecting one little one October 2013.
Found out at 6 mos that our little one had died weeks earlier and had to induce and deliver stillborn, July 25, 2013.
Something found on adrenal gland at follow up ultrasound, MRI showed what seems to be a benign tumor. Meeting with specialist Jan 8, 2014 - all fertility treatments on hold. :/
Tumour is definitely producing Aldosterone (causes high blood pressure) and Cortisol. Lucky me, only 34 similar cases recorded in the world! Tumour removed May 2014.
Approached about a possible adoption March 2014. Rush through all the paperwork and process.
Charlotte Evangeline born June 27, 2014. We brought her home on July 7 and held our breath for 10 days until she officially became ours.
Surprise BFP October 2014. Due to wonky cycles, ultrasounds convince Doctors I have a blighted ovum but detailed ultrasound reveals heartbeat at 6w3d. On progesterone support and waiting to see if pregnancy is still viable. Holding our breath again.
Adalyn Marie born on June 9, 2014 after a roller coaster pregnancy.

#9 eyedoc

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Posted 27 April 2014 - 10:10 PM

Insurance companies will do anything to exclude from coverage! Most insurance companies, if they even cover anything, cover portions of the drugs and not the procedure itself. DH has an awesome insurance plan for almost everthing, but unfortunately doesn't cover anything fertility related. So we will be paying for everthing, including the drugs. And you're right - it is pretty crazy to spend so much money on something that has no guarantee. But what other choice do we all have? Good luck!
  • gibasgirl likes this

Me - 33, PCOS
DH - 38, Male factor

April 2012 - Started TTC #1
2013 - 2014 - Several medicated cycles and 3 IUI - all BFN

November/December 2014 - IVF #1
Transfer of 1 day 5 embryo, 3 embryos frozen - BFP th_abfp.gif
pPROM @ 35 weeks and our baby babygirl.gif made her early appearance on July 26, 2015

 

July 2015 - Phone consultation with clinic to look at doing a FET towards the end of the year

August 2015 - Natural BFP??  th_abfp.gif  We are in shock!  Ultrasound at clinic confirms I was already 9 weeks pregnant and had NO IDEA!

Due date for baby B #2 - March 27, 2017


#10 CdnHockeyGal

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Posted 27 April 2014 - 10:31 PM

MJMacD - It would likely be a fruitless excercise to obtain a private plan for coverage...it's certainly possible that there is a program out there that would offer you limited benefits...but I'd be pleasantly surprised.  I work in the industry and most policies are worded to the effect that if you have or suspect you have any condition for which you may or may not yet have consulted a physician...it's a pre-existing condition.  If you've already had a conversation with your GP...you're likely not eligible for any coverage.  Truly...the best course of action is to call the inquiry line for your group benefits provider (you can obtain this from your plan administrator, in your group benefits booklet or on your group benefits card) and see if the DINs for the drugs that are recommended are covered.  You'll likely find that some of the drugs prescribed will have some coverage due to multiple usage.  It's always worth enquiring of your benefits provider if any of the drugs that aren't covered would be considered "exceptional status" and covered if your prescribing doctor filled out an E2 or an E3 form.  Your MD may charge you for completing the paperwork...but it's a lot less expensive than paying out of pocket.


It was long, awful & hard. We got very lucky and didn't run out of both emotional and financial resources. We saw some of the most beautiful of people in our lowest moments. Baby Girl arrived Apr 10/2018





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