29 replies to this topic

[Watermelon]

Hello wise women (and men)

I recently decided to look into the details of my DH insurance policy given that the cost of IVF is often half drugs and wanted to be prepared if we end up proceeding to IVF in the future.

His policy specifically states that infertility drugs/procedures etc. are NOT included. However just for fun I got a list of DIN numbers for most of the medications commonly used in IVF and typed them into the company's online coverage search and almost all were covered?! The only one not covered was puregon.
Absolutely every other drug was 100% covered.

I am guessing this is because many are used for purposes outside of IVF. My question is, for those of you that have a similar policy and have submitted claims for such drugs, did they reimburse you? Did they request more information? I don't want to be foolish enough to get my hopes up. Insurance companies are not stupid....but wow it would sure take some of the stress off if a lot was covered!

[kerrilyn]

Did you check gonalf too? The FSH drugs used to stimulate your ovaries will be the most expensive portion.

[Sweetheart]

Mine was the same and all the drugs were reimbursed except for Viagra and that was not because it is a fertility drug but because they had an exclusion for "erectile dysfunction".  If you have a drug card, it is best to use this rather than paying up front. That way, they can't change their mind!

[Sweetheart]

FSH drugs were not covered because they are not used for anything but fertility.

[SGD]

My DH's insurance told me that they don't cover fertility medications when I called them when we started trying 4 years ago.
I decided to submit the claims anyway just to see and sure enough, they paid for them!
I put them through my insurance first, and they cover all of my meds. Whatever is not covered (because of the specific plan that I chose) I put through DH's, and they have reimbursed all of my claims.

I would go by the DIN info. And I agree with one of the previous posters, use your drug card so that it's covered up front.

[Watermelon]

Our policy requires us to pay out of pocket and then submit, so no getting by with the drug card unfortunately....but it is really fascinating and hopeful to hear that this might work.

All other stimulation drugs, including gonal f and menopur were covered. Only puregon was rejected. Bizarre. I'm not aware of what else besides ART these drugs are used for?

I just hope they don't close this loophole before we need to access it!

[CdnHockeyGal]

As you indicated above...it has more to do with the possible multiple uses for a drug...so...unless they are specifically fertility related your drug coverage plan may well provide you with reimbursement.  You can always call for pre-approval before purchasing the drugs as well.  It's not a loophole but more to do with multiple uses for any particular medication...your treating physician can prescribe a medication for an off-label purpose (off-label is when a drug is effective for treating a condition it wasn't developed for)...if the drug can be used for more than one purpose...it should be covered as there's every reasonable possibility you're not using it for fertility purposes.  Lupron is frequently used to treat endometriosis so it's often covered on plans that exclude for fertility drugs because who's to say you're not being treated for endo...same thing with Fermara...developed for breast cancer...but effective as an ovulatory agent...hence...an off-label use. 

 

Hope this helps!

[Hopingfor1]

For me, we had a limit on fertility drugs. Estrace & Progesterone weren't included in that limit but the others such as Gonal F & Menopur were based on DIN numbers.  Once our limit was reached they rejected any further payments for those drugs.

[GraceM]

On my plan, any drug that can be prescribed for multiple uses is not a fertility drug. Any drug that is solely used for fertility is classified as a fertility drug and is put towards my fertility drug coverage of twenty thousand.

[north]

I'm curious to know which insurance companies people are dealing with and what results they're having....?

My plan is GreatWest Life. My partner's plan is also GreatWestLife.

My plan says it covers up to $5000 in a lifetime for fertility drugs. I haven't submitted the uncovered amounts to his plan but I think I should just to see what happens!

[Hopingfor1]

I'm curious to know which insurance companies people are dealing with and what results they're having....?

My plan is GreatWest Life. My partner's plan is also GreatWestLife.

My plan says it covers up to $5000 in a lifetime for fertility drugs. I haven't submitted the uncovered amounts to his plan but I think I should just to see what happens!

My plan was also Great West Life.  Each employer decides on the package and mine was $6,000 per lifetime.  My husband's was a union plan and it was $12,000 per lifetime.

 

Submit the uncovered amounts to your husband's plan - the worst they can do is reject it but hopefully the coverage is per person and doesn't matter that both your employers picked the same insurer.

[CdnHockeyGal]

Spouses can have the same insurance provider (i.e. both can be GWL) and as long as you have opted into "family coverage" rather than "single life" coverage it's irrelevant that it's the same provider. Each group program has it's own individual contract number and each insured member has their own plan member number within the master group contract. You are entitled to the benefits available to you under each plan number you may have. Your own group program will always be the primary payor and your spouse's the second payor. This means you may need to submit a claim to your own plan knowing it will be denied and send it the claim & the denial to your spouse's plan to coordinate the benefits.

Every group benefits program is designed by the company owner and/or plan administrator and they determine if the plan will include fertility drug coverage. Some drugs will have multiple uses or off label uses that mean you could have some coverage regardless of actual "fertility" drug coverage. You should always submit any claim and let them adjudicate if it will be paid or not.

Hope this helps!

[moomac]

Thanks

[Anaïs]

I had coverage from GWL. They had up to $20K life time coverage for fertility treatment including drugs & IVF.

They covered everything except for some fertility test (which is really weird because one needs some testing done before embarking on IVF journey).

I now have coverage from Sunlife (my husband too) and they cover everything except for syringes.

[amandaTTC#2]

We were on GWL for a while but I can't remember if it was with them or Manulife I checked coverage. Our plan had the exclusion of fertility drugs mentioned above, only estrace and progesterone were covered when checked DINs. But remember that you can claim any amount not covered by insurance on your taxes, so keep records and for when you file next year!

[SunshineTTC]

I've got Sunlife and my plan covers nothing, other than the very few meds that are also used for something other than fertility... and those tend to be the cheap one anyway.  E.g. BCP, Estrace, Prometrium.  It's frustrating (and expensive) for sure.

[maryd]

Thanks for this post! I didn't bother to submit any receipts since fertility is completely excluded....and it seems still most of mine was rejected, but they partially covered the prometrium so we got $80 back which is better than nothing!

[Highest hopes]

This is great info.  Wish I would have known to try it....

 

For those of you with coverage for fertility drugs, just curious who these employers are?!  It's pretty rare to gave a good benefit plan like that.

[s00n]

Public Service Health Care Plan -  (federal government) offers 80% drug coverage, with no exclusions for fertility medications.  This is through Sunlife.

Empire health is my husband's coverage (small private company) and they offer lifetime max of $4000 fertility drugs.

[maryd]

Public Service Health Care Plan -  (federal government) offers 80% drug coverage, with no exclusions for fertility medications.  This is through Sunlife.

Empire health is my husband's coverage (small private company) and they offer lifetime max of $4000 fertility drugs.

 

We have Empire with zero coverage for fertility so varies from company to company depending on their plan I guess. 

[s00n]

Huh.  Interesting.  Did they cover semen analysis, if you had to get it done?  We submitted and they covered the Kruger as a diagnostic test.

[CdnHockeyGal]

In theory any insurance company will offer fertility drug coverage - but the employer has to request it be built into the plan...which increases the cost to the employer significantly.  GWL is the only insurer that offers full coverage with no maximum as a default...the employer has to request it's removal.  Manu offers some limited coverage as a default...the employer has to request it's removal.  Every other provider has to specifically have that benefit added on.  Hope that helps!

[s00n]

Funny thing at the pharmacy this morning, at my clinic.

 

My plan (PSHCP) allowed automatic insurance coverage at the regular 80%, but husband's plan Empire declined coverage.  When I phoned they figured it was excluded.  It took 10 minutes on the phone for the guy to figure out that I have to do a paper submission, so I've got that paperwork all done up now.  Not as good as coverage at the pharmacy but still good.

[maryd]

Huh.  Interesting.  Did they cover semen analysis, if you had to get it done?  We submitted and they covered the Kruger as a diagnostic test.

 

No it was declined.

[s00n]

:/ plans are all so different. Sorry yours was declined.