Understanding Insurance Coverage

Understanding Your Insurance Coverage

It is important that you know what your benefits cover to ensure you understand your potential out-of-pocket costs. Your member services number is listed on the back of your card. Listed below are the most common types of insurance coverage and some questions you may want to review with your insurance carrier.

Types of Insurance Coverage

• HMO – These plans usually only offer in-network benefits. In addition, you will usually have to provide a referral for any visit.
• POS – These plans usually offer in and out-of-network benefits. However, you may still need a referral in order to maximize coverage.
• PPO – These plans offer both in and out-of-network coverage. You usually do not need a referral or authorization for these services either, but should always verify this with your insurance carrier.

Questions to Ask Your Insurance About Benefits

• Does my plan cover testing for infertility?
• Does my plan cover assisted reproductive treatment?
• What procedures require preauthorization?
• What limits, if any, apply to your coverage? (# of treatment cycles, procedures, months of therapy, embryo transfers, & age of patient)
• What is the maximum dollar limit on my infertility benefits? Does this maximum include prescriptions? If so, what portion is allocated to prescriptions, and what is allocated for treatment?
• Is the maximum dollar benefit lifetime or annual?
• What is the coinsurance or copayment for medical services?
• What is my out-of-pocket maximum and does it include my deductible?
• When does my plan year begin and end?
• What procedures are listed in the exclusions section?
• Do I have to undergo “lesser before greater”?  This means, would I have to do IUIs before IVF?
• Does voluntary sterilization affect my benefits?

As always, please remember that you, the patient, are calling member services. Unfortunately, there are times that they provide incorrect information. RADfertility will also verify your benefits with physician services and review them with you. Until actual payment is received, benefits are not guaranteed.

Questions to Ask Your Insurance About Pharmacy Benefits

• Is there drug coverage?
• Are infertility drugs covered under the pharmacy benefit or medical benefit?
• What is the coinsurance or copayment for drug coverage?
• What prior authorization policies are in effect for medications?
• Are there 30-day drug prescription limits for infertility medications?
• Does the plan pay for self administered subcutaneous, under the skin injection (SQ) and/or oral (PO) medications?
• Does the plan pay for intramuscular (IM) medications?
• Are there discounts for mail order medications?
• Are infertility specialists encouraged to prescribe one drug over another?
• Can I get a medication that is not a preferred drug or formulary? Can I get a medication that is not covered? If so, am I expected to pay a higher copayment or coinsurance or pay for it completely? And what is that amount compared to the preferred drug copayment or coinsurance?

Always record when and who you spoke with, as well as the reason and the outcome. It is also suggested that you obtain a written pre-determination of your benefits. This is your most effective tool if you need to challenge a future decision made by your insurance company.