Patient Resources

Be Smart with Your Infertility Insurance Benefits

July 26, 2011 – With only a handful of health insurance companies in North Carolina providing benefits to cover infertility treatments, it’s more important now than ever to know what you’re spending.  

Dr. Sameh K. Toma, Medical Director of the North Carolina Center for Reproductive Medicine, warns patients to beware of treatment options that could drain what little medical or prescription coverage you may have.  For example, if a patient has a lifetime benefit of $5000, she should carefully consider how to move forward by choosing the path that would result in the best chance at conceiving a child.

At NCCRM, most patients get pregnant without having to go through in vitro fertilization (IVF), by means of timed intercourse, ovulation induction and intrauterine insemination (IUI).  
Here is an example of a basic treatment plan and its associated costs compared to other fertility clinics in our region:

Pregnancy rates for both of these treatment plans are usually within 5% of each other, resulting in a 10% – 15% chance of conceiving per cycle.  Yet, the cost is dramatically different.  “Examine your benefits and look at the best chance of getting pregnant,” says Dr. Toma.  “Just because a treatment costs more doesn’t mean it has higher success rates.”  

Many patients also may need a laparoscopy to evaluate the fallopian tubes, presence of endometriosis, polyps, fibroids and other issues.  Another procedure often recommended by OBGYNs and fertility specialists is a hysterosalpingogram (HSG).  It’s a special kind of x-ray that involves placing an iodine-based dye through the cervix and taking x-rays to help evaluate the shape of the uterus and whether or not the fallopian tubes are open or blocked.  “It’s important to note that an HSG only confirms whether the fallopian tubes are open but says nothing about the freedom of the tube to pick up eggs from the ovary,” explains Dr. Toma.  Instead, a saline ultra sound followed by air infusion into the fallopian tubes can assess the patency of the tubes as well as the HSG, but would be covered as a gynecologic procedure rather than a fertility procedure with a woman’s insurance company, thus saving any fertility coverage she may have for other procedures.  The saline ultrasound also is used to detect polyps and fibroids.

In summary, it’s critical that patients understand all aspects of their medical and pharmacy benefits.  Here is a list of specific questions every patient should ask their health insurance company and pharmacy benefit provider before moving forward with any treatment protocol:

Do I have benefits to cover testing for infertility??
Do I have benefits for reproductive technology procedures such as IUI and/or IVF?  If yes, what is the lifetime dollar maximum or the maximum number of attempts??
Do I have benefits for infertility drugs??
Is the fertility clinic an in-network provider with your insurance company?

Fortunately, NCCRM has a very experienced and knowledgeable team that can help patients navigate their way through the complex world of health insurance.  For more information, visit www.NCCRM.com.


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