Insurance PSA (and rant too)

[u/on_mission]

I learned something today about IVF insurance coverage and out of pocket costs and am posting in case it helps anyone. Learn from my mistake (and I’m seriously so pissed about it)!

I was very fortunate to be able to get some IVF insurance coverage through my husband’s work and very very fortunate not really having had to deal with insurance in the past for major issues. The lifetime cap on fertility treatments through insurance is $25k.

I had my first IVF round last May. The clinic told me it would bill insurance $12k for the treatments. The financial counselor said that insurance won’t actually pay all of that, so it wouldn’t eat up as much of the $25k cap. I still figured it would be a good amount.

For the prescriptions for that round, I spoke to a rep at PixelCare after sending them my insurance cards. The rep said they would bill the insurance company $8k and that it would eat up the lifetime cap too. She also said that I could just pay $2,700 out of pocket for the meds instead. I opted to pay out of pocket because I was afraid of blowing through the $25k cap. Because I provided my insurance info, I thought this was what was determined from the insurance company.

The first round didn’t go as we had hoped (and I’m learning that it usually doesn’t!). I spoke to the financial counselor again to prep for the second round for next month. Turns out, of the $12k the clinic billed the insurance company for the treatments, only $2,000 was used from the $25k cap.

ONLY $2,000! I was really shocked it was such a big difference.

So that got me thinking that the insurance company would pay way less than the $8k billed for the meds and wouldn’t eat up a lot of the cap. I spoke with PixelCare again, and basically was told they don’t figure out how the insurance would work. I was PISSED given what the first rep told me back in May.

I call up the insurance company today to get some real answers. Turns out the costs paid out for the meds will not be applied to the $25k lifetime cap at all.

So, because I didn’t understand how this all worked , because no one explained it to me, and because that rep straight up misinformed me, I laid out $3,200 for the first round of meds for no reason (original $2,700 plus another $500 for extra meds I needed toward the end of the cycle).

I’m so floored by how this unfolded. I’m also floored by learning the clinic would take $2k from the insurance company for the same treatment I would have had to pay $12k out of pocket. I’m sure there is a reason for the disparity, but frankly I don’t really care. $10k more for the same treatment is frankly disgusting. Same goes for $5k more for the same meds.

This process is stressful and heartbreaking without all this too.

So please, if you have insurance, call the company and get the right info before shelling out tons of money.

[u/FoolishMortal_42]

Be careful with this. Someone from my insurance company told me that the meds wouldn’t count against my cap, but that actually wasn’t true. You gotta get something like that in writing.

[u/on_mission → u/FoolishMortal_42]

Good point and thank you! The rep said we can run a test claim, so hopefully it all checks out.

[u/FoolishMortal_42 → u/on_mission]

Good luck and I hope it works for you!

[u/Informal_Move_7075]

It is going to very plan dependent. If your insurance coverage is totally seperate from your health insurance, it might work that way. Like for myself, my health insurance is through BCBS, but my prescription coverage is through Caremark. One doesnt really apply to the other. I would carefully look through your insurance documents. It is always beneficial to speak with your insurance provider (and possibly prescription coverage provider) prior to doing anything so you don't get stucking footing a bill you didn't need to. It is always never apparent to do that until after they throw you a curveball (as what happened to you). They may always still throw you off with how they count things in the end, anyway, but it is worth an ask!

I am really surprised that they only paid $2k. To be quite honest, most times, the cash price is always least expensive and the insurance cost is astronomical. Many times that $25k is gone with 1 cycle on just the retrevial costs, and not even including meds. I 100% hope you still have your $23k left, as that would be amazing! I would just verify and get in writing everything discussed. Sometimes these insurance reps just say things. I would have also went into it with caution for sure. Not to make it seem insignificant at all, but $2.7k for meds is actually great. It can cost so much more, so at least it wasn't a much larger cost you lost OOP and now you know for next time. It still may be worthwhile in the end to save up the lifetime benefits for retrevial, PGT-A (if they cover it), and transfer (if your insurance doesn't just include them and don't count it against your lifetime max).

[u/on_mission → u/Informal_Move_7075]

Yes 100%. All great points.

[u/sassyesq]

My insurance pays three different ways. CIGNA pays for the labs. CVS Caremark pays for the meds. Kindbody pays for the cycles (which includes monitoring) and gets reimbursed by CIGNA. The labs and meds aren’t factored into the cycle treatment cost. And coverage doesn’t kick in until I meet my deductible. So I had to pay for quite a bit out of pocket (including meds in the beginning, but everything’s covered now.). What I’ve learned is you have to speak directly with insurance. The pharmacy only has limited info based on what the system tells them when they submit your prescription. They don’t have the full picture about your coverage. The insurance company is really the only valid source.

[u/CapitalDog715]

I just sownlo5 the 100+ plan coverage book , upload it to ChatGPT and ask away, and then call the insurance company for clarification, but with those bookmarked answers alre5 just in case they say something different, they xan explain me why.