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Tips for Changing Insurance

Insurance benefits are employer driven, each purchasing specific benefits and services for their employees. To find out your specific benefits, request a benefit booklet from your employer or human resources (HR) department. Even if you have the same plan, benefits and out-of-pocket expenses may change from year to year. Here are a few tips for comparing and changing insurance plans.

  • Check for pre-existing exclusions. Individual and small group policies typically have pre-existing clauses. Typical pre-existing conditions 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 exclusions may be prior sterilization, donor services, intrauterine insemination (IUI), and/or in vitro fertilization (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? Do medications contribute to the benefit maximum?
  • Try to find out if the plan has a medication benefit for fertility drugs. A medication (pharmacy) benefit is typically separate from your medical benefit.
  • Understand the differences between HMO/POS/PPO plans. Most HMO plans require that you see your PCP to obtain an referral and an authorization to see a specialist.
  • Decide if you want to go through your primary care physician (PCP) to see a specialist and obtain referrals or have the ability to go directly to the specialist. Some insurance plans require pre-authorization.
  • Compare out-of-pocket expenses among different plans, including deductibles, co-insurance, and any co-pay amounts (some policies have up to a 50 percent co-pay for fertility services).
  • Check to see which healthcare providers or hospitals are in-network.
  • Check your insurance coverage to determine if there are specific medical criteria you must meet to be eligible for benefits. For infertility, criteria may include:
    • A 2-year history of infertility or infertility associated with one of the following:
      • Endometriosis
      • Diethylstilbestrol (DES) exposure
      • Blocked or surgically removed Fallopian tubes
      • Abnormal male factors contributing to infertility
    • Patient’s eggs must be fertilized with her spouse's 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

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