If we have infertility coverage on our health insurance?

[jezuzgirl]

It says we have 20,000 in infertility coverage. (Lifetime Infertility Services Maximum). Can anyone tell me how this works? Can we use this for In Vitro Fertility Costs? We are with Aetna (POS II)

[Zachary's-Mom]

Call the customer service number on the back of your insurance card - they can give you all the details that are specific to your plan.

[Mindy]

I would call the insurance company just to see everything that is covered and exactly how it will all work. Also make sure you ask them to give you a list of the doctors you could go to because you do not want to end up somewhere where they for whatever reason are not contracted with that doctor!

[kobesilas]

Call your insurance company and ask them. They should be able to tell you what is all covered.

[collegegirl71581]

I'm assuming that it will cover whatever fertility treatments you need in order to achieve the desired outcome (pregnancy), which would include IVF. Use the $20,000 wisely. You might want to try the cheaper procedures first, such as IUI so you don't use it all up needlessly. I wish I had insurance that covered infertility (been ttc for 10 years) but unfortunately I don't even have any insurance at all. Could you send some baby dust vibes my way? Here's some baby dust for you****

[disabledvetwife]

This is from aetna's website:

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Clinical Policy Bulletin:
Infertility


Number: 0327


Policy


Notes:

For purposes of this entire policy, Aetna covers diagnostic infertility services to determine the cause of infertility and treatment only when specific coverage is provided under the terms of a member's benefits plan. All coverage is subject to the terms and conditions of the plan. The following discussion is applicable only to members whose plans cover infertility services.

For purposes of this policy, a member is considered infertile if he or she is unable to conceive or produce conception after one year of frequent, unprotected heterosexual sexual intercourse, or six months of frequent, unprotected heterosexual sexual intercourse if the female partner is over age 35 years. Alternately, a woman without a male partner may be considered infertile if she is unable to conceive or produce conception after at least twelve (12) cycles of donor insemination (six cycles for women age 35 or older). However, this definition of infertility may vary due to state mandates and plan customization; please check plan documents.

Infertility services are considered not medically necessary once pregnancy is established and a fetal heartbeat is detected. Infertility services beyond eight weeks of pregnancy are not considered medically necessary.

Females: Basic Infertility Services

The following services are considered medically necessary for diagnosis and/or treatment of infertility.

History and physical examination
Laboratory studies:

Anti-sperm antibodies (e.g., immunobead or mixed antiglobulin method)
Chlamydia trachomatis screening (See CPB 433 - Chlamydia trachomatis - Screening and Diagnosis.)
Post-coital testing (PCT) (Simms-Huhner test) of cervical mucus
Fasting and 2 hours post 75 gram glucose challenge levels
Lipid panel (total cholesterol, HDL cholesterol, triglycerides)
Rubella serology
Serum hormone levels

Androgens (testosterone, androstenedione, dehydroepiandrosterone sulfate (DHEA-S) if there is evidence of hyperandrogenism (e.g., hirsuitism, acne, signs of virilization) or ovulatory dysfunction
Gonadotropins (serum FSH, LH) for women with irregular menstrual cycles (see Appendix for medical necessity limitations) or age-related ovulatory dysfunction. Note: Aetna considers urinary FSH testing to be experimental and investigational. Serum, not urinary, FSH is the standard of care for determination of menopausal status (AACE, 1999; NAMS, 2000; SOGC, 2002)

Note: Some plans exclude coverage of infertility services for women with ovarian failure, defined as an FSH level 19 mIU/ml on day 3 of any menstrual cycle. Please check benefit plan descriptions.

Human chorionic gonadotrophin (hCG) (see Appendix for medical necessity limitations)
Prolactin for women with an ovulatory disorder, galactorrhea, or a pituitary tumor
Progestins (progesterone, 17-hydroxyprogesterone) (see Appendix for medical necessity limitations)
Estrogens (estradiol) (see Appendix for medical necessity limitations)
Thyroid stimulating hormone (TSH)
Adrenocortitrophic hormone (ACTH) for ruling out Cushing's syndrome or Addison's disease in women who are amenorrheic
Clomiphene citrate challenge test

Karyotype testing for couples with recurrent pregnancy loss (two or more consecutive spontaneous abortions) (See CPB 348 - Recurrent Pregnancy Loss.)
The following laboratory studies are considered experimental and investigational:

Serum inhibin B measurement (value in assessing ovarian reserve is uncertain)
Antiprothrombin antibodies (See CPB 662 - Antiprothrombin Antibody Testing.)
Embryotoxicity assay (See CPB 348 - Recurrent Pregnancy Loss.)
Endometrial function test (EFT) (cyclin E and p27).
Note: Many plans exclude coverage of home pregnancy tests and home ovulation test kits. Please check benefit plan descriptions.

Diagnostic procedures:

The following diagnostic procedures are considered medically necessary:

Endometrial biopsy
Hysterosalpingography (hysterosalpingogram (HSG)) or hysterosalpingo-contrast-ultrasonography to screen for tubal occlusion
Laparoscopy and contrast dye to assess tubal and other pelvic pathology, and to follow up on hysterosalpingography abnormalities.
Hysteroscopy, salpingoscopy (falloscopy), hydrotubation where clinically indicated.
Ultrasound (e.g., ovarian, transvaginal, pelvic) (see Appendix for medical necessity limitations)
Sonohysterography
CT or MR imaging of sella turcica is considered medically necessary if prolactin is elevated
Monitoring of ovarian response to ovulatory stimulants:

Serial ovarian ultrasounds are considered medically necessary for cycle monitoring (see Appendix for medical necessity limitations)
Estradiol (see Appendix for medical necessity limitations)
FSH (see Appendix for medical necessity limitations)
hCG quantitative (see Appendix for medical necessity limitations)
LH assay (see Appendix for medical necessity limitations)
Progesterone (see Appendix for medical necessity limitations).

Nonsurgical treatments:

The following nonsurgical treatments are considered medically necessary:

Estrogens (e.g., estrone and conjugated estrogens (Premarin))
Corticosteroids (e.g., dexamethasone, prednisone)
Progestins (oral or intramuscular progestins and progesterone vaginal suppositories, see CPB 510 - Progestins )
Metformin (Glucophage) combined with clomiphene citrate for anovulatory women with polycystic ovary syndrome who have not responded to clomiphene citrate
Prolactin inhibitors (bromocriptine (Parlodel), cabergoline (Dostinex), peroglide (Permax)) for women with ovulatory disorders due to hyperprolactinemia
Ovulation induction:

Ovulation induction with oral clomiphene citrate (Clomid, Serophene) or tamoxifen (Novaldex).

Note: The medications listed above may not be covered for members without pharmacy benefit plans; in addition, some pharmacy benefit plans may exclude or limit coverage of some or all of these medications. Please check benefit plan descriptions for details.

The following non-surgical treatments are considered experimental and investigational:

Leukocyte immunization (immunizing the female partner with the male partner's leukocytes) (See CPB 348 - Recurrent Pregnancy Loss.); and

FSH manipulation of women with elevated FSH levels. (An elevated FSH level is a marker of reduced ovarian reserve, as occurs with advancing age. Elevated FSH-related (i.e., age-related) infertility has not been proven to be affected by interventions to reduce FSH levels.)

Infertility surgery:

Laparoscopy for treatment of pelvic pathology
Ovarian wedge resection or ovarian drilling for women with polycystic ovarian syndrome who have not responded to clomiphene citrate
Removal of myomas, uterine septa, cysts, ovarian tumors, and polyps
Open or laparoscopic resection, vaporization, or fulguration of endometriosis implants plus adhesiolysis in women with endometriosis
Laparoscopic cystectomy for women with ovarian endometriomas
Hysteroscopic adhesiolysis for women with amenorrhea who are found to have intra-uterine adhesions
Tubal ligation (salpingectomy) for women with hydrosalpinges who are contemplating in vitro fertilization, as this has been demonstrated to improve the chance of a live birth before in vitro fertilization treatment
Hysteroscopic or fluoroscopic tubal cannulation (salpingostomy, fimbrioplasty), selective salpingography plus tubal catheterization, or transcervical balloon tuboplasty for women with proximal tubal obstruction (See CPB 347 - Transcervical Balloon Tuboplasty.)
Surgical tubal reconstruction (unilateral or bilateral tuboplasty) and tubal anastomosis) for women with mid or distal tubal occlusion and for women with proximal tubal disease where tubal cannulation has failed or where severe proximal tubal disease precludes the likelihood of successful cannulation.

Note: Most plans exclude coverage for reversal of sterilization surgery (including sterilization by tubal ligation or vasectomy) and exclude infertility services for couples in which either of the partners has had a previous sterilization procedure, with or without surgical reversal, and for females who have undergone a hysterectomy. Please check benefit plan descriptions for details.

Females: Additional Infertility Services

The following additional services (referred to in some plans as "Comprehensive Infertility Services") may be considered medically necessary if the member is unable to conceive after treatment with Basic Infertility Services, or if the member's diagnosis suggests that there is no reasonable chance of pregnancy as a result of Basic Infertility Services.

Injectable medications (See CPB 020 - Injectable Medications.)

Gonadotropin releasing hormone (GnRH) (luteinizing hormone releasing hormone (LHR-H)) by intermittent subcutaneous injections or by GnRH infusion pump (See CPB 501 - Gonadotropin-Releasing Hormone Analogs and Antagonists for additional information and limitations.)

Gonadorelin (Synarel, Factrel)
Goserelin (Zoladex)
Leuprolide (Lupron)

Considered medically necessary for the following indications:

For use, in addition to gonadotropin stimulation, in pituitary down-regulation as part of in vitro fertilization treatment (Note: coverage of GnRH for this indication is limited to plans that cover advanced reproductive technologies. Please check benefit plan descriptions for details.)
Pulsatile administration of gonadotropin-releasing hormone is considered medically necessary in women with WHO Group I ovulation disorders (hypothalamic pituitary failure, characterized by hypothalamic amenorrhea or hypogonadotropic hypogonadism) (see appendix for WHO classification of ovulation disorders).

Gonadotropins

Human chorionic gonadotropi