Tips for Verifying or Changing Insurance

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Important Benefits Information

Benefits are employer driven. Employers purchase specific benefits and services for their employees.

To find out what your specific benefits are request a benefit booklet from your employer. Even if you have the same plan, benefits and out of pocket expenses may have changed.

Check for pre-existing exclusions. Individual and small group policies typically have pre-existing clauses. Typical pre-existing condition may state no documented history of infertility or may have a pre-existing condition waiting period. Typically 9 months to 1 year.

Review benefit exclusions. Examples of benefit exclusion may be prior sterilization, donor services, IUI, and/or IVF

Check to see if you have an annual or lifetime benefit maximum - How much does this plan cover for fertility services or the number of cycles covered?

Try to find out if the plan has a medication benefit for fertility drugs. Medication (pharmacy) benefit typically is separate from your medical benefit .

Administrative Requirements

Decide if you want to go through your primary doctor to see a specialist and obtain referrals or have the ability to go directly to the specialist. Understand prior authorization requirements.

Compare Costs

Compare out of pocket expenses:

  • Deductibles
  • Coinsurance
  • Co-pay amounts- Some policies have up to 50% co-pay for fertility services

Networks

Determine if your current healthcare providers and area hospitals are in the network

Medical Criteria

Most policies have medical eligibility requirements

Check medical coverage/policies to determine what specific criteria you must meet to be eligible for benefits

Examples of Medical Criteria:

  • 2 year history of infertility or infertility associated with one of the following: Endometriosis, DES exposure, blocked or surgically removed fallopian tubes, abnormal male factors contributing to infertility
  • Patient’s egg’s must be fertilized with her spouses sperm
  • Patient has been unable to obtain successful pregnancy through any less costly infertility treatments covered by insurance
  • Prior sterilization of patient or partner may exclude coverage

Learn about the Maryland Mandate

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