Here are some secrets I have learned over the past year in regards to getting my Infertility & IVF Medications Fully Covered (TWICE) through my Student Health Insurance
For those who have read my Kevin MD article (Find under Publications) and watched the KevinMD Podcast Episode (below) know I have been dealing with trying to get my infertility injectable medications covered a second time for a 2nd ovarian follicle stimulation for embryo freezing.
Multiple times when the pharmacies or insurance company would submit a claim for my infertility medications they would be "DENIED" with a reason that my insurance plan "did not cover infertility treatment."
However, I learned that a denial from a health insurance administrator DOES NOT mean you have to accept that denial. You have the power to advocate and fight for your right to receive the medical care your doctor believes is best for you. You can do this through submitting prior authorizations, appeals, working with patient advocates, informing them on government mandates, involving advocacy organizations/foundations, or asking for supervisors and specialists in the billing department. Yes, I did all of these...The goal of health insurance companies is to save as much money as possible and are rarely are the representatives trained in medicine. Unfortunately, it is up to the patient & their medical team to fight for getting the medical treatments patients need and deserve.
Therefore, after 6+ months and over 20+ hours on the phone going between my University's Health Insurance, different Specialty Pharmacies, my doctor's office, and patient advocates I have finally gotten them fully approved and covered (a SECOND TIME)! My total out of pocket was $300 as a copay which included the injectable medications, syringes, and other common medications needed for the IVF cycle.
Read more at my article co-written with Dr. Dr. Ariela Marshall and published by the Endometriosis Foundation:
"An Inside Look into Infertility Care: Navigating Hidden Costs & Treatment"
New Things I Have Learned since the KevinMD article and podcast episode:
The State of IL has a Mandate for all health insurance's provided by companies employees are mandated to cover fertility testing and infertility treatment (ovarian stimulation,IVF, Follicle Stimulation, etc)
"(215 ILCS 5/356m) (from Ch. 73, par. 968m) Sec. 356m. Infertility coverage. (a) No group policy of accident and health insurance providing coverage for more than 25 employees that provides pregnancy related benefits may be issued, amended, delivered, or renewed in this State after the effective date of this amendatory Act of the 99th General Assembly unless the policy contains coverage for the diagnosis and treatment of infertility including, but not limited to, in vitro fertilization, uterine embryo lavage, embryo transfer, artificial insemination, gamete intrafallopian tube transfer, zygote intrafallopian tube transfer, and low tubal ovum transfer.
(b) The coverage required under subsection (a) is subject to the following conditions: (1) Coverage for procedures for in vitro fertilization, gamete intrafallopian tube transfer, or zygote intrafallopian tube transfer shall be required only if:
(A) the covered individual has been unable to attain a viable pregnancy, maintain a viable pregnancy, or sustain a successful pregnancy through reasonable, less costly medically appropriate infertility treatments for which coverage is available under the policy, plan, or contract;
(B) the covered individual has not undergone 4 completed oocyte retrievals, except that if a live birth follows a completed oocyte retrieval, then 2 more completed oocyte retrievals shall be covered; and
(C) the procedures are performed at medical facilities that conform to the American College of Obstetric and Gynecology guidelines for in vitro fertilization clinics or to the American Fertility Society minimal standards for programs of in vitro fertilization.
(2) The procedures required to be covered under this Section are not required to be contained in any policy or plan issued to or by a religious institution or organization or to or by an entity sponsored by a religious institution or organization that finds the procedures required to be covered under this Section to violate its religious and moral teachings and beliefs.
(c) As used in this Section, "infertility" means a disease, condition, or status characterized by: (1) a failure to establish a pregnancy or to carry a pregnancy to live birth after 12 months of regular, unprotected sexual intercourse if the woman is 35 years of age or younger, or after 6 months of regular, unprotected sexual intercourse if the woman is over 35 years of age; conceiving but having a miscarriage does not restart the 12-month or 6-month term for determining infertility;
(2) a person's inability to reproduce either as a single individual or with a partner without medical intervention; or
(3) a licensed physician's findings based on a patient's medical, sexual, and reproductive history, age, physical findings, or diagnostic testing.
(d) A policy, contract, or certificate may not impose any exclusions, limitations, or other restrictions on coverage of fertility medications that are different from those imposed on any other prescription medications, nor may it impose any exclusions, limitations, or other restrictions on coverage of any fertility services based on a covered individual's participation in fertility services provided by or to a third party, nor may it impose deductibles, copayments, coinsurance, benefit maximums, waiting periods, or any other limitations on coverage for the diagnosis of infertility, treatment for infertility, and standard fertility preservation services, except as provided in this Section, that are different from those imposed upon benefits for services not related to infertility."(Source: P.A. 102-170, eff. 1-1-22.)
- STUDENT HEALTH PLANS ARE EXCLUDED FROM THE ILLINOIS MANDATE of having to cover Infertility medications. Thankfully, my University included Infertility Treatment and medications as part of the covered plan. Unfortunatly, somehow this got coded incorrently on the insurance end and my injectable medications kept being denied with the response "these medications are not covered in the insurance plan."
- Through working with a Student Health Plan Advocate and "high up" special billing case manager at the Health Insurance, the case manager has the ability to OVERRIDE each medication denial.
- The increased costs of infertility testing and treatment are some of the many barriers to Family Planning for individuals in lower SES, Black and Brown individuals, the LGBTQ community, & those without health insurance.
Important Groups & Phone Numbers:
Accredo: Specialty Pharmacy only covering medical benefits (all injectable meds) - 800-660-4283, 800-803-2523 Main numbers - 855-891-7977, 888- 608-9010 accredo billing dept
Freedom Fertility - Pharmaceutical Specialty pharmacy under Acredo only does meds covered under pharmaceutical benefits - 877 585 4603
Express Scripts- the pharmacy actually shipping medications - (407) 852 4937
BCBS Pharmacy Services Department - 800-423-1973 - Case Manager Specialist Alyssa (8am—4pm M-F) - Have to manually input of overrides of medication denials of pharmacy - Make sure to keep track of Case Number
Student Health Plans Advocates: - http://ahpcare.com - Excellent Patient Advocate: Rebecca.Hale@ahpcare.com
5 Injectable Medications Worth $10,000 Out of Pocket (Got Covered by insurance twice!!)
These medications are usually covered under medical benefits on not pharmaceutical benefits so have to go through the specialty MEDICAL Pharmacy not the Specialty Pharmecetical Pharmacy (silly I know). I had to explain this concept to each representative I spoke with and got transferred back and forth each time I called which took 1-2 hours each phone call.
J Code = How the pharmacies & insurance classify the medication (used in ICBM system)
MOA = Mechanism of Action
Ganirelix - J Code: SO132 - MOA: GnRH antagonist - 8pm every night
- 6 days - $1,464 total for 16 vials
- Need Prior Authorization - Covered as Specialty and Dispense Limitations
https://www.bcbsil.com/PDF/rx/rx-list-enhc-il-2021.pdf
https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/021057s010lbl.pdf
Follistem - J Code: SO128
- MOA: Has both FSH and LH, Utilizes recombinant DNA - SE: fatigue, headache, wt gain of up to 5lbs of fluid
- $4,617 for 12 days - Small needle with pen - Keep in Fridge!!! - Covered as Specialty and Dispense Limitations
https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/021211s011lbl.pdf
Menopur (menotropins) - J Code:SO122
- MOA: Has both FSH and LH
- $3,164 for 36 vials and 12 days - Mix with liquid prior to injecting
Leuprolide (Lupron) - J Code: J9217
- MOA: GnRH agonist in pulse, untag if continuous - 4 days - Subcutaneous Trigger kit - SE: headaches, photoflash, depressed (low estrogen)
Novarel - J Code: JO725 - MOA: chorionic gonadotropin, cHCG- acts like LH surge to release eggs - SE: bloating
- 1 day, SQ or IM in glute
- Need Prior Authorization
https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/017016s156lbl.pdf
When an Insurance requests a pre-authorization this is the list of information you will need to provide to your insurance (or doctor's office if they do it for you).
ex: Endometriosis (N80.9)
ex: Tubal Occlusion (N97.5 & N97.1)
- Name of Infertility Doctor and the Address of the Infertility Clinic
- Health Records with the exact same Diagnosis Codes
Letter of Agreements (LOA):
Sometimes Health Insurances deny the prior authorizations and you can submit for a Letter of Agreement as a type of Appeal which goes in front of a board to decide if they are willing to pay for your procedure. This is similar to the Prior-Authorization but sometimes they also want a letter from the Fertility Doctor explaining why the medications are critical to your health/procedure.
For More Resources Check out:
- My Infertility Resources
- My Blog & Instagram Posts on Infertility