Ep 345: Fertility & IVF Insurance and How to Get the Most From Your Fertility Benefits

0:00Dr. Carrie Bedient: You're listening to the Fertility Docs Uncensored Podcast, featuring insight on all things fertility from some of the top-rated doctors around America. Whether you're struggling to conceive or just planning for your future family, we're here to guide you every step of the way.

0:21Dr. Susan Hudson: This episode is brought to you by Receptiva DX. What if unexplained infertility isn't actually unexplained? For many women, hidden inflammation associated with endometriosis and other uterine conditions can go undetected for years, even when everything else appears normal. For more than a decade, fertility specialists have trusted Receptiva DX to provide deeper insight into the uterine environment, helping women and their physicians uncover answers and make more informed treatment decisions.

0:52Dr. Carrie Bedient: Hello, and welcome to another episode of Fertility Docs Uncensored. I am one of your hosts, Dr. Keri Bedian from the Fertility Center of Las Vegas, joined by my splendiferous colleague, Dr. Susan Hudson from Texas Fertility Center.

1:05Dr. Susan Hudson: Hey, Keri. How are you doing today?

1:07Dr. Carrie Bedient: Good. How are you doing with your new piece of jewelry?

1:09Dr. Susan Hudson: I am good. So I just got a ring con. It's one of these biometric devices, kind of like the Oura Ring and stuff like that. In our household, we're pretty against things that you have to have a subscription for.

1:23Dr. Carrie Bedient: Yeah.

1:23Dr. Susan Hudson: It's so tricky once you get a subscription for something and then you forget about it and then three years go by and you're like, huh, what's this like? $12.99 every month. It's a set price and you get the app and then you get the information. It's not currently FDA approved, but I know they're going for FDA approval. I've only had it for a few days now, but I like it.

1:48Dr. Carrie Bedient: I had an Oura Ring in the past. I kind of stopped wearing it because it didn't actually really. I don't think helped me a whole heck of a lot. I may revisit that, but still. So what does it pick up your sleep and your heart rate and your temperature and whether you're about to blow up your husband?

2:04Dr. Susan Hudson: Well, it does have a headache prediction factor.

2:08Dr. Carrie Bedient: Is that an internally motivated headache or an externally motivated headache?

2:13Dr. Susan Hudson: It was actually pretty interesting because I had turned on that part of it. That's one of the optional things is headache prediction. and I hadn't had a headache at all. And then last night I started getting a bad headache and I was like, huh, I wonder if it's picking it up. And I opened up my little app and it was like, you're at risk of having a headache. And I was like, oh, nifty.

2:32Dr. Carrie Bedient: So does it send you an alert for that? If you routinely check that three times a day, would it give you enough advance notice to know, oh, I should take the Advil now?

2:42Dr. Susan Hudson: I don't know yet. I've only been doing it for three days. A lot of these things I'm still learning. Uh-huh. I do think it sent me an alert that said I was at risk for a headache, but I didn't pay attention to it. But it's interesting. The sleep one, it says how much light sleep you have, how much deep sleep, and how much REM sleep you have. It shows your movement. It shows your pulse through the night. There is a segment where you can do, like for general health, that does blood pressure, but you have to set that up. I haven't set that up yet.

3:16Dr. Carrie Bedient: But do you have to, for the blood pressure, you can't get that from the rain, can you?

3:19Dr. Susan Hudson: So somehow you calibrate. You have to have a blood pressure cuff to get it set up. My mom, who lives two doors down, has one. I just haven't gotten it and done the calibration thing. But yeah, somehow it's supposed to measure at least some perspective of blood pressure. It says stuff about hydration status, your temperature, your stress level. Of course, it does your steps. which I was actually impressed. I was doing more steps than I thought.

3:48Dr. Carrie Bedient: That's always exciting.

3:49Dr. Susan Hudson: On a day that I drove back from Corpus Christi, I still had over 6 ,000 steps. That's not bad for being in clinic and driving for three hours and then being at home. I'd like to have more in, but again, 6 ,000 steps isn't terrible for that type of a day.

4:05Dr. Carrie Bedient: No. Does it tell you about your stress in a way that is meaningful, like that you wouldn't have already known?

4:13Dr. Susan Hudson: I really can't comment about that yet because in the time that I've had the ring, I haven't had any major swings one way or the other. I haven't really felt like super stressed about anything acutely. Okay. Yet to be determined.

4:30Dr. Carrie Bedient: Well, maybe this will inspire me to go put my aura ring back on and see if there's any value to it.

4:35Dr. Susan Hudson: Yeah. Okay. So.

4:37Dr. Carrie Bedient: Interesting. Cool. Yeah. Okay. So what's our question for today?

4:41Dr. Susan Hudson: Okay. So our question for the day is, hi, I'm 23 years old, husband is 25, about to start my first round of IVF. I had a recent laparoscopy that identified stage 3 endo and had to have my right ovary and tube removed. Left tube is patent with clubbed fembria. Husband's semen analysis normal. My AMH is 1.3, FSH 16.4, estradiol 55 on cycle day 2. My REI is concerned that we may not be successful even with IVF based on my labs and clinical picture. Do y 'all share the same sentiment concern? Are there any recommendations you have to increase the chances of success? Currently taking CoQ10, OVA NAD, DHEA, and prenatal.

5:27Dr. Susan Hudson: Thank you.

5:28Dr. Carrie Bedient: Wow, all that at 23. Yeah. So the biggest thing that comes to my mind is pretreatment with a medication to drop her FSH going into the IVF cycle so that there is a bigger difference between where she starts and where she ends up. That can be some people use birth control pills. Some people use cetratide ganorelix, one of the GNRH antagonists. Some people do a Lupron flare for this. My personal favorite is I do a couple days more Lyssa leading into the cycle to drop levels. That would be the first thing that pops into my mind to drop her FSH levels and to help prevent a cyst at her baseline that's going to throw her off a little bit.

6:04Dr. Carrie Bedient: She's 23. That is easily, hands down, the best thing she's got going for. And that is a huge, huge thing. And that's huge not only for the quality of eggs she's going to get now, but also for the time it affords her. If, let's say she does this first cycle and it's not successful. Well, at 23, you can maybe come back at 24, 25 and do another one, as opposed to if you are 41 doing this, coming back at 42, 43 is a big deal. Nobody wants to wait, but she has a much better, bigger picture overall than many of our other patients do who have age working against them.

6:39Dr. Susan Hudson: Absolutely.

6:40Dr. Carrie Bedient: What do you think? Anything that pops in your mind?

6:42Dr. Susan Hudson: Well, when I look at it, I'm actually pretty happy with her AMH being 1.3 considering we're down an ovary. I think that has a lot to do with your young age. And your FSH being 16, really kind of surprising. And I'm wondering if it's some reflection of the endometriosis, looking at the quality of the eggs, maybe considering some omnotrope or growth hormone during your stimulation. I don't usually use growth hormone in an initial stimulation, but in someone who's down an ovary and we have an FSH of 16, I think it's probably worthwhile for something. When I do it, I do a quarter of a vial an evening for up to 12 days of stimulation.

7:29Dr. Susan Hudson: So it's about$1 ,200. And although$1 ,200 is not something to laugh at in the grand scheme of how expensive IVF is, I think that you want to do as few cycles as possible to ideally build your family. And I would be more aggressive. I totally agree with estrogen priming or however we want to help suppress that FSH level. Understanding that the medications we're giving you, whether it's Gonal F or Follistim or Menopur, all of those have an FSH component. So we really want to kind of hit your ovaries hard at the beginning to get those little follicles growing. And ideally, hopefully you'll get quite a few.

8:10Dr. Susan Hudson: Also understand no ovarian reserve testing is perfect. And IVF is not only therapeutic in that we're helping you trying to achieve pregnancy, but it's also diagnostic. And what I mean by that is we are going to get an idea of what your eggs actually look at. We're going to have an idea of is the membrane surrounding the egg? Does it have the right kind of strength or is it really flimsy? Are we seeing signs of degradation within the egg? Are we seeing vacuoles or debris? Or is it a nice, pretty egg that we would expect to see from somebody who's 23? So there's things that we're going to learn during this cycle.

8:51Dr. Susan Hudson: And again, ideally, we're one and done. But if not, there are going to be things that your doctor is going to be able to add to their armamentarium after they see how you actually respond.

9:03Dr. Carrie Bedient: One thing I would also think about just for her to know in the back of her mind with the other tube that is patent, but with clubbed fimbria, essentially meaning they don't have the dexterity that you would normally want from fingers. They're not as easily able to pick things up. I would say if she's missing a period, if she thinks she might be pregnant at all, to be very diligent about just having a bunch of dollar store pregnancy tests that she can be on a stick. Because if something comes up positive, especially if it's a spontaneous conception, we want to know where that is and we want to follow that from a very early stage.

9:38Dr. Carrie Bedient: That would be my little side tip of get a bunch of cheapo pregnancy tests so that if you need to use one and test one because your period is late, even if it's super stressful because your mother-in-law brought meatloaf over, whatever, maybe unannounced, that you know that you're not at risk for that. I think that's good advice.

9:58Dr. Susan Hudson: Let's play a game. How many tabs do you have open right now about IVF? One says your chances are great. Another says they're terrible. Reddit has one opinion. TikTok has another. Facebook is full of horror stories. And somehow, after two hours of searching, you have more questions than answers. Sound familiar? That's exactly why we wrote the IVF Blueprint. This isn't another fertility book filled with opinions or miracle cures. It's an evidence-based guide that walks you through every stage of IVF, from understanding your fertility evaluation and choosing a treatment plan, to medications, egg retrieval, embryos, genetic testing, transfers, and the two-week wait, and beyond.

10:42Dr. Susan Hudson: Because the last thing you need during IVF is more noise. Close the tabs, put down your phone, open the IVF blueprint instead. Available now wherever books are sold.

10:56Dr. Carrie Bedient: All right, so today we are going to be talking about how to maximize your insurance coverage as you're going through infertility treatment and the diagnostic testing, IUIs, IVF, all of those things. First thing to discuss is what is the general structure of insurance coverage? Like what are the big general ways that can work for people to know about?

11:20Dr. Susan Hudson: So the first thing is to understand when it comes to fertility care, we generally have two main pathways. One is your diagnostic coverage and the other is your treatment coverage. And your insurance may have diagnostic coverage only. Your insurance may have treatment coverage only. That's a little more unusual. Or you may have no coverage for diagnostics or treatments, or you may have coverage for both diagnostics and treatments.

11:52Dr. Carrie Bedient: Okay, let's start with diagnostic coverage because that's what most people coming to us, whether or not you go through treatment, odds are if you're coming to us, you're very likely to go through the diagnostics just so you have an idea of what's going on. What's the big overview of the tests that we are looking at for doing diagnostic testing?

12:13Dr. Susan Hudson: So diagnostic testing are the basic things that we're going to do to try to get the lay of the land or figure out your personal puzzle as to what exactly is going on with your specific fertility challenges. We're going to do some ovarian reserve testing. Generally, that's going to be some blood work. Most often, it's going to include something called an AMH or anti-mullerian hormone. A lot of us still use FSH or follicle stimulating hormone in conjunction with estradiol and also an ultrasound to look at your antral follicle counts, looking at the little resting follicles on your ovaries. Now, when we do that ultrasound, We're also looking at the rest of your pelvis, looking at the uterus, making sure we don't see the fallopian tubes because we really don't want to see them on ultrasound.

12:59Dr. Susan Hudson: If we do, that can be concerning. But included in that diagnostic testing are your HSG, your hysterosalpingogram, where we put some dye within the uterus and goes through the fallopian tubes to see if the tubes are healthy, appearing, and open. There are some other types of evaluations that can be done on fallopian tubes, either with bubbles or with foam or other types of contrast material. And there may be other blood work looking at your other health parameters, especially if we're concerned about somebody who may have irregular periods or trying to figure out if you may have PMOS. Other parts of diagnostics include testing on your partner, whether that be blood work or testing on the sperm.

13:48Dr. Susan Hudson: Now, Carrie, what are some of the tests that we may do more specifically on men versus what?

13:53Dr. Carrie Bedient: So for men, we're looking at blood work. Most of us are just looking at infection disease panel testing for that. Not because we think that he's been up to anything inappropriate, but because we're working in labs that use a lot of different material going through. So we are very particular about if something needs to be quarantined, we want to make sure that we've got that testing. We do genetic carrier screening. And then in addition to the semen analysis, we may order a DNA fragmentation. We may order additional blood work looking at the hormones that contribute to sperm production and male hormonal health.

14:29Dr. Carrie Bedient: And then we may look at a sperm QT. that is independent often of whether or not we need somebody to go see a reproductive urologist, which is a different physician who specializes. Those types of physicians are urology trained, and if we need to do any sort of sperm extraction, they're the ones who help us out. They will also often help us out with medications that guys need in order to bring up their sperm count, if that's something that's in the plant. When you have somebody who has insurance, let's say woman calls for the appointment and she's got solid insurance with diagnostic coverage. Does that include his coverage as well?

15:07Dr. Susan Hudson: It does not. So the testing that's going to be covered under diagnostics is whatever that particular insurance holder has. So if she has insurance and he does not, her insurance is not going to cover male testing. You each need to have either shared policies where you're both on the same policy or individual policies. Your clinic is used to working through all of that minutiae. So don't stress over it being like, oh my goodness, there's so many things going on here. We're used to handling it. It's just that for it to be covered under insurance, you have to have coverage under your own name. Now, what we probably see most often is she has coverage and he does not, which in the grand scheme of things is not usually that They give a deal.

15:57Dr. Susan Hudson: You may have to pay some money for his testing and some money for his particular interventions, but that is usually much less expensive than what a female partner who is going through the actual fertility treatment is going to undergo. So what causes usually the most strife is him having insurance, her not having insurance, and then none of the things that are really expensive for her being covered, even though one partner. If y 'all are sitting at home listening to this podcast or watching us on YouTube and you're like, hmm, I'm thinking about getting fertility testing. As you are heading into your re-enrollment, open enrollment period for jobs, be very aware of who may have coverage, who doesn't have coverage.

16:49Dr. Susan Hudson: And ideally, both of you getting coverage so that you get the most out of your benefits from your employer.

16:55Dr. Carrie Bedient: So let's say that a couple is planning that. They need to change up her insurance in order to improve their coverage. And her best friend has insurance company A as her covering provider, and she's got amazing insurance. This person who's undergoing treatment or diagnostic testing is going to sign up for it is from the same company. Does that automatically mean she's going to get amazing coverage? No.

17:21Dr. Susan Hudson: So what's most important is, first of all, it doesn't matter whether it's Aetna, Blue Cross Blue Shield, Humana, Cigna, United, any of those major names, because what matters is what your employer has contracted with those insurance companies. If you work for the same employer, you still may not have the same coverage because there's usually multiple policies that you can choose from. And if you have three different policies, very often one of them will have the fertility coverage of some way, shape or form, but the others may not. So you need to make sure what your specific employer contracts with the insurance and also knowing the differences of the policies.

18:12Dr. Susan Hudson: Just because you may work for company X, not all policies under company X may cover the same amounts, if anything at all.

18:23Dr. Carrie Bedient: How does it work if someone needs diagnostic testing and she has insurance, but she doesn't specifically have fertility coverage and she still needs to get the tubal testing, the ultrasounds, the blood work? How does who is ordering that test make a difference and how does the coding make a difference here?

18:44Dr. Susan Hudson: So first of all, for the most part, and this has changed, I would say, within the past five or 10 years, it doesn't matter if your fertility doctor or your OB-GYN or your family medicine doctor is ordering a test. It all has to do with what is the diagnosis code that is accompanying it. They're not penalizing you because you're seeing a fertility doctor. They may be just penalizing you based on what the code is. Now, if you have something else going on other than just infertility, like if you have painful periods, irregular periods, what are some other things that kind of fall into these things?

19:25Dr. Carrie Bedient: Fibroids, pain with sex, hot flashes, mood swings, vaginal discharge. There's an awful lot that can potentially come in.

19:33Dr. Susan Hudson: There's a lot of things in there. If there's something else we can identify as a problem, some of these tests may qualify as diagnostic tests related to that. However, if you don't have any of those things, we have to code it under fertility testing because otherwise that is insurance fraud.

19:54Dr. Carrie Bedient: None of us look good in orange.

19:56Dr. Susan Hudson: Orange is not our color. We want you to have the best coverage ideally available to you, but we also can't break the law. If there is something else going on, like I said, a lot of times at least some of the testing may get covered, but it may not be everything. And understand that insurance companies can request records and they can request the whole set of records and they can go through and be like, well, sometimes they agree to it and sometimes they don't. Insurance companies can be a little challenging that way.

20:29Dr. Carrie Bedient: And sometimes if they pay us for a service that they did, they will go back and they will re-review those records and they will claw back that money if they think they paid it out when they shouldn't have. And with respect to who orders it, in general, yes, it is better. But there are still some insurance companies that are unique to Nevada that I know I should not order anything because it's going to come under fire. But if I can have the OBGYN order the same exact things, that they're much more likely to get it covered. Now, a tube test is a tube test no matter what it is. That is always for fertility.

21:05Dr. Carrie Bedient: And so that one, you're out of luck. But the infection testing, for example, and some of the diabetes screening, prolactin levels, things like that, oftentimes an OBGYN can get through that better. But again, codeine doesn't cover absolutely everything. what you may, one complaint like vaginal discharge that may be able to get infection testing covered, may not be able to get all the other blood work covered. And so there's a lot to know about this. And I really wish I could tell you that it was easy. And even with our office having multiple dedicated billing and insurance people whose entire job is to sort this out, it's still challenging.

21:48Dr. Carrie Bedient: We still have to fight back. We still have to go through everything very carefully to make sure that we're maximizing what you can get. And also, we're not going to go to jail.

21:57Dr. Susan Hudson: Another couple of things kind of to segue here is understand that even when you have coverage, you're still responsible for your deductible and co-pays. If you have a$350 deductible, great. But a lot of people have$1 ,000,$2 ,000,$5 ,000 deductibles, which means you're going to pay up to that. And that's where your insurance starts with the partial payments and things like that. A lot of times you still have a copay where you have to pay a certain percentage. And there's also the wonderful, heartbreaking, stressful event of getting what's called an EOB. An EOB stands for explanation of benefits.

22:35Dr. Susan Hudson: The biggest thing that we probably order that causes the biggest heart attack is carrier screening.

22:41Dr. Carrie Bedient: Always. Carrier screenings. Oh my God, always.

22:44Dr. Susan Hudson: Where we're looking for things that hide in the family tree until the right person meets the right person. These are genetic tests and genetic tests on the surface are very expensive. Most insurances nowadays do cover carrier screening and you'll receive something called an explanation of benefits. So this is something that a company that's doing the carrier screening gives a huge number and then your insurance is actually going to pay something else. And it's more as something that legally they have to show you all of the stuff that's happening behind the scenes. Well, you are still responsible for your deductible and copay.

23:22Dr. Susan Hudson: Also know that most of these companies also have maximum cash pay pricing. So say I was going in to do my fertility evaluation and I I haven't spent any of my deductible and I get an explanation of benefits that says something like$13 ,000. No one is going to pay$13 ,000 for carrier screening. Now you might, under some circumstances, have to meet your deductible from that, but even that would be a little bit of a stretch. But most of them are going to have cash pay pricing of something like$250 for the test. Just being aware you have options, but also know that if you choose that cash pay price, it does not go towards your deductible.

24:09Dr. Susan Hudson: So you're choosing to take that outside of the circle of insurance. So you may be paying less, but understanding how that deductible and cash pay pricing interact is very important.

24:21Dr. Carrie Bedient: Is every provider covered by and accepting every insurance plan?

24:27Dr. Susan Hudson: No, we have to be contracted with insurance plans. Providers can pick and choose which insurance plans they want to work with. And there are some plans that most people in the fertility world don't work with. Most of them are the government plans like Medicare and Medicaid, TRICARE, those types of things.

24:49Dr. Carrie Bedient: Most of which do not cover fertility treatment anyway. Like for Medicare, Medicaid, there's there is absolutely no coverage for it. So that is less of an issue of us taking it versus not as even if we all did, it doesn't make a difference. I'm not going to pay for anything that we do.

25:06Dr. Susan Hudson: Exactly, exactly. And for our TRICARE folks, also know a lot of clinics do give military discounts. So ask about that because we do want to help you along your journey because we very much appreciate the service that you have rendered for us in our country. But there's also insurance companies that are very difficult to work with, that have very poor reimbursements, and you just have to call and ask your clinic, hey, do you take this insurance? If you're on a bigger national insurance, it's more likely that it's going to be accepted. The smaller the insurance company, the less likely, because each one of those is a separate contract with its own separate rules.

25:47Dr. Susan Hudson: It gets a little daunting. So, Keri, when we're looking at transitioning from testing over to treatment, what are some things to expect?

25:59Dr. Carrie Bedient: Prior authorizations. That is easily one of the biggest things. For the most part, we don't have to get prior auths for the diagnostic testing. Because for the most part, the diagnostic testing that we're doing in the world of medicine is not that expensive. However, once you get to treatment and you start talking about considerably pricier treatment options, that's when the insurance company wants a prior authorization. And the prior authorization says the clinic slash patient has asked the insurance company, this is what we want to do. Are you going to pay for it? And then the insurance company says yes or no.

26:37Dr. Carrie Bedient: And usually they have criteria or limits on it. What I see the most often is we have to get a prior auth for IUIs and they will say, yes, you are good for three IUIs up until this date, six months in the future, or three months or four months, or your grandmother Tilly's birthday, whoever it may be. Those prior auths take a couple weeks to come back. Now, oftentimes when the patient calls the insurance company, the insurance company will say, yes, you need a prior auth. Just have your clinic mark it stat. And the only thing that the word stat is good for is getting a giggle. Because stat, especially in the fertility world, when we put stat on something, it does not change a single damn thing.

27:19Dr. Carrie Bedient: And there's some insurance companies that have faster turnaround times than others. But when our insurance or billing people call the company and they say, hey, this woman's period is about to start in four or five days. Can you turn this over? They just laugh at us. And I don't know if you experienced that in the same way in Texas. I think it's been relatively uniform in the various places that I have practiced and trained. But needing that prior auth and needing the time to get it and enact it is real. Maybe your period is going to start in a week, but we're actually going to start that IUI cycle in a week plus one month for your next cycle so that we've got time to get your auth back.

27:57Dr. Carrie Bedient: Because if you start going through a treatment cycle without having auth, they will not cover it.

28:02Dr. Susan Hudson: And I would say in the absence of a cancer diagnosis, that it's almost impossible to get anything to go faster than whatever fast is going to be. Some of the companies are very fast. And the ones that specialize in fertility care, like Progeny and Maven, they tend to do pretty quick offs. Those that do not, United. it's going to take two to three weeks to get that through and especially when it comes to IVF we won't start an IVF cycle until we have authorization because the last thing we want to happen is you have talked to your employer you've talked to HR we've talked to your insurance everybody says it looks fine and then we put in a pre-off and it gets declined for some reason and then you're sitting there and you're like well I just did this$25 ,000 IVF cycle that I thought was going to get paid for and now it's not getting paid for and tomorrow is my egg retrieval and somebody wants me to lay down$10 ,000 -$15 ,000 cash.

29:11Dr. Susan Hudson: IVF is stressful enough without that type of surprise. We want to make sure we have our I's died, T's crossed, not only for the medical part, but also for the financial part, because honestly, that can sometimes be the most stressful part of the whole ballgame.

29:26Dr. Carrie Bedient: Often, yeah. What is the difference between what state you live in and what kind of coverage you may have?

29:33Dr. Susan Hudson: Very good question. So there are certain states within the United States that have mandates that are determined by the states as to what type of fertility coverage must be granted via your insurance. And that can vary anywhere from making sure you have testing coverage to making sure you have unlimited coverage to you have coverage under certain conditions. Those conditions could be as simple or complex as everybody who has a cancer diagnosis has availability through their insurance to do fertility preservation to others that everybody in the state is granted three IVF cycles if they're under 45 years of age under these other circumstances.

30:22Dr. Susan Hudson: There are states that have mandates and it's actually interesting because a lot of times we'll see people who their primary company is in a state that has a mandate though they live in a state that is not mandated but they have really good coverage because the employer is governed under that particular state's mandates. And so they have to be granting coverage to people who are outside of that state. It's a crazy little web we maneuver within. But like I said, it's the web we're used to living in.

30:55Dr. Carrie Bedient: Now, let's say somebody has fertility coverage. Is absolutely every diagnosis going to qualify you for that fertility coverage.

31:03Dr. Susan Hudson: No. And again, it depends on the plan. It depends on the stipulations for either the mandates or your actual employer has put in stipulations. The thing that comes to mind the most often for a diagnosis that's excluded would be a history of prior sterilization procedure. So whether you've had your tubes tied or the guy has had a vasectomy, Though it is less common than it used to be, there are quite a few policies that state that if you've had a prior sterilization procedure, that you don't qualify for the fertility coverage that would have otherwise been. I actually saw one recently that you could have a history of sterilization, but you had to have a history of sterilization, sterilization being reversed, and then still needing fertility coverage after that.

32:02Dr. Susan Hudson: I hadn't seen that before, but that was a new one to me. As you can tell, this is an ever-evolving issue, and we see it. And that's one reason. Anytime I have somebody who comes in and they have a history of a tubal ligation or a vasectomy and they have coverage, the first thing I'm doing is messaging my front desk and being like, are we sure we don't have any exclusion policies? Because I know these people are coming in to talk about IVF, and they think they have coverage, but I want to make sure you truly, truly have coverage before we get too far down the line.

32:36Dr. Carrie Bedient: Is third-party reproduction, egg donation, sperm donation, surrogacy, how does that work with insurance?

32:43Dr. Susan Hudson: Much, much less likely to be covered under insurance. However, even if the general concept is not covered, there's often things that it will cover. So it may cover your embryo transfer. It may not cover the IVF cycle to retrieve the eggs from the donor and create the embryos, but when it comes to your embryo transfer, it may be covered. Very, very few policies cover anything having to do with a gestational carrier. If they do have some coverage, it's probably a relatively small amount in comparison to the actual amount it costs to do a gestational carrier cycle. Most recently, I saw one that there was$25 ,000 in gestational carrier coverage, which sounds great.

33:29Dr. Susan Hudson: The problem is if you're doing gestational carrier through an agency, that's going to cost you a minimum of about$150 ,000 to$200 ,000 at a minimum. So that$25 ,000 is great, but it's actually a pretty small percentage of the whole dollar amount. And also if you're using things like donor sperm, you may be limited to certain sperm banks. If they cover the purchase of donor sperm, again, it just varies. But this is really where talking to your clinic, talking to your insurance provider, you're going to be able to get a lot of information and a lot of guidance.

34:07Dr. Carrie Bedient: One other theory of partial coverage that just popped into my mind is PGTM. And I have had patients in the past where both partners have carried a condition that we need to be concerned about, or one of them will have an autosomal dominant condition, meaning they're going to have a 50 % chance of passing it onto a child. I've seen the insurance company cover the PGTM, but not cover the IVF cycle.

34:29Dr. Susan Hudson: Yeah. And even with PGTA, so the testing for chromosomes, there's a lot of insurance companies that will cover your IVF, but the PGTA is still not a covered benefit. So again, knowing the big picture of what your doctor wants and advises for you to do and what you and your partner want and what you feel comfortable with, it all goes into the alphabet soup.

34:55Dr. Carrie Bedient: One of the things that I always talk about with my patients is in addition to knowing your benefits, thinking about them critically and how to maximize them. So, for example, there are some insurance companies that will say, you have six cycles of IUI, period, end of story. Okay, great. You may not be the perfect candidate for IUIs, but maybe in order to take advantage of your insurance, we say, okay, we're going to go through all six of those because that's what's covered. And if we still don't have a pregnancy, then we think about IVF. There are other plans that may require you have access to IVF, but you need to do so many IUIs first.

35:32Dr. Carrie Bedient: Well, we play by their rules. Now, sometimes we can argue that and say, hey, she has both tubes blocked. This is stupid. And sometimes that works and sometimes it doesn't work. The situation where I think is the most important to really think about is the situation where you have a set dollar amount of benefit. Let's say you've got$25 ,000 in benefit. Use it however you want, but once it's gone, it's gone. Those are the cases where we really need to be cognizant of how much time do we spend doing on low-key things that are less invasive but also way less effective. Because we don't want you to do 3, 4, 5, 6 cycles of IUI, burn through the majority of your benefit, only to discover we still need to do IVF.

36:20Dr. Carrie Bedient: And we lost the advantage of your benefit because we were trying to do things that have a 5, 10, maybe 15 % success rate.

36:26Dr. Susan Hudson: Other things to think about when you're trying to maximize, I wanted to say manipulate, but I'm going to say maximize how you're using your benefits. Sometimes you have a pharmacy allocation and sometimes you have a medical treatment allocation, but sometimes it's all together. Okay. And more and more nowadays, it's$1 amount to cover everything. So sometimes people are like, oh, I'm just going to try to use up my insurance benefit as we go. And as the event happens, I'm going to pay for it. And when we run out, then we'll cover it from there. This is the problem with this. So if you're using your pharmacy benefit, they are going to tell you what pharmacy you have to use.

37:10Dr. Susan Hudson: Now, if you've been on any other blog, social media things, you'll know that a lot of times fertility medications are ordered from mail order pharmacies. These are not brick and mortar pharmacies like your local CVS or Walgreens. And when we order your medicine through one of these specialty pharmacies, they usually tend to be as competitively priced as possible within reason. When your insurance company dictates you have to use this particular pharmacy, oftentimes that pharmacy is charging you a lot more than you would have paid for the same medication through another mail order pharmacy. I'm going to make up numbers here, so please do not hold me to this.

37:56Dr. Susan Hudson: But say you buy a Gonal F pen that has 300 units. To make math easy, we're going to say that that 300 unit pen now costs you$200 if you ordered it through what we would consider our typical mail order pharmacies, we order our medication. Well, if you order it through the insurance's declared pharmacy, you may pay$300,$350 for what you could have paid cash for$200. So sometimes saying, hey, I'm going to pay for my medications, cash or with financing or however we're going to make that happen, take that out of the insurance equation and pay for the actual medical treatment, the ultrasounds, the blood work, the egg retrieval, the embryology fees, pay for those out of my insurance benefit can make the best sense in the long term.

38:52Dr. Susan Hudson: Another way to do things, and this isn't necessarily something that we talk about a lot because we know everybody wants to be pregnant yesterday. And once you kind of get in the mode of everything, you kind of get where you want to be. But if you're thinking about having multiple children, especially if you're into your mid to late 30s or 40s, sometimes going through and using your IVF benefit to create embryos now to be used in the future. And then maybe trying something a little bit easier if you're a good candidate right now to get pregnant for that first baby and saving those embryos to be used in the future is very important.

39:36Dr. Susan Hudson: Carrie, what would you advise about people who have really good fertility benefits right now in their current job?

39:43Dr. Carrie Bedient: Take them and run. And I mean that in every possible way you can imagine it because fertility benefits can change. Jobs can change. What you're willing to pay for in your monthly benefit can change. What your spouse has can change. If you know right now that you happen to have really great benefits, we have seen this happen all too often where someone is coming in because they know in three months they're about to lose all their fertility benefits. And at that point, it is a mad dash to get them through whatever part of their cycle we can before their coverage lapses. And that's also considering we have to do our due diligence.

40:25Dr. Carrie Bedient: We can't just throw you into a cycle tomorrow when you saw us for the first time today because we have to know a few things. We have to know, are you anemic? Do your platelets work? Do you have any infections? All of the diagnostic testing we do, we do for a reason because we need to make sure that you know what you're getting into and that we know what we're getting into and that if there's any extra measures or finessing that we have to do to a treatment plan, we can do that. And so if you know that you've got great benefits for the love of all that is holy, please take advantage of them because it is incredibly common for those benefits to change over time.

41:00Dr. Carrie Bedient: I've seen couples come in where they don't have any known fertility problem, but they know that they're about to lose an IVF benefit. And so they bank embryos because that's going to be the only way that they will get fertility coverage if they end up having a problem. Or they want a bunch of kids and they're not ready to start yet. Whatever it may be, keep an eye on those benefits because if you're about to lose them, knowing that a month before is not enough time to use them and these things change all the time. Susan, what do you think about the specialty infertility insurance companies? Progeny, Carrot, Maven, that set of groups.

41:36Dr. Susan Hudson: In general, love them. I have to say as somebody who serves what I consider middle of America, I don't live and work in a city that's super high tech, super sexy, where it's all the moving and grooving. I help everyday normal people. And I think the best thing that has happened is these types of entities have been able to bring fertility treatment options and coverage to normal everyday people. In general, I think they're fantastic. Again, they can be a little bit challenging to understand all the how do my cycles work and what are the pros and cons, but in general, they have really good coverage.

42:21Dr. Susan Hudson: They're very non-discriminatory and they're pretty easy to navigate. And I would recommend for all of the big names that you just mentioned, they all have people on their staff to help walk you through it. So even though you have crazy busy lives and everything else is taking priority, sometimes taking a 30 minute break to get on the phone and be like, hey, I truly want to understand what in the world is a smart cycle. How do these 12 or 24 credits pertain to what I'm wanting to accomplish? There are people who will sit down with you. And that is their entire job is to help their patients, their subscribers, I guess would be the best term, to be able to understand and maximize their benefits.

43:12Dr. Susan Hudson: So in general, I'm a huge fan. What about you, Keri?

43:16Dr. Carrie Bedient: I tend to really like them as well because it means I get to do what I do as a doctor and can focus more on what is needed, what do we have to do, and how are we most effectively going to get you pregnant. I don't have to worry about it nearly as much as the financial, which as a physician, I am the least qualified person in the office to talk to about your financial stuff. And that is true of most of us as physicians. We've got the overview, but there's so many nuances to coverage and in all of the details that go through it, that asking your physician financial questions is not typically a very fruitful conversation.

43:50Dr. Carrie Bedient: And I will tell my patients, if I give them any financial information at all, that they absolutely cannot tell my financial office that I said anything and that if they do, I will 100 % deny it because there's just such a high likelihood that about that set of information, we don't have all the information and we can't advise you in the same way. Going through and working with the benefits that those companies provide, not just for financial coverage, but for navigation and how do you work through it can be very, very valuable. Susan, are all aspects of pregnancy care going to be covered at a fertility clinic?

44:27Dr. Susan Hudson: Unfortunately, no. But again, it varies on your plan. So you may be on medications to help support your pregnancy that may or may not be covered, like progesterone. Sometimes it changes the moment you have a positive pregnancy test. So your progesterone oil for your IVF may not have been covered. but as soon as you have a positive pregnancy test, sometimes it's covered. And again, it varies from plan to plan. We do tend to do more ultrasounds than you would get in standard OBGYN care. I would say a lot of them get covered. Most of them get covered, but it's not a universal thing. If you're having problems, I would say generally, yes, it's the same as anything else, but also understand for the vast majority of reproductive endocrinologists, so those of us who do fertility medicine, that we will only see you through a certain part of your first trimester.

45:28Dr. Susan Hudson: And after that, you're transitioning your care over to your general OBGYN. And right now, the OBGYN landscape is vastly changing because in the world of insurance. It's gone from obstetric care being a package under your insurance to now it's becoming an a la carte type of situation, which we have always worked in relatively the a la carte world. But there's a lot of changes happening right now. And honestly, we are not probably the best people to voice that. But I would say in general, if you have insurance, a lot of your care is going to be covered, it may not all be covered. Absolutely.

46:13Dr. Carrie Bedient: All right. This has been hopefully a really helpful episode for all of our listeners. The one thing that I would leave you with, particularly if you have no insurance coverage, is go talk to HR. Go talk to your employer, because if they know that this is important to their employees, it makes it a lot more likely that at least they'll look into it. And sometimes it only takes one or two really squeaky wheels to change the culture for an entire company. And so you never know how that may benefit you. Asking for the fertility-specific benefits and an easy coverage can be really exceptionally helpful.

46:51Dr. Carrie Bedient: It is perhaps easier than you may think to at least ask the question. You may not get the answer you want, but asking the question does a benefit for you and for everybody who's coming after you.

47:01Dr. Susan Hudson: All right.

47:02Dr. Carrie Bedient: Well, thank you so much for spending a part of your day with us.

47:06Dr. Susan Hudson: If you enjoyed this episode, subscribe, leave a review, and send us your questions at fertilitydocsandcensor.com.

47:12Dr. Carrie Bedient: If you want even more infertility information, pick up a copy of the IVF Blueprint, which is a practical guide to understanding fertility treatment, IVF, and the decisions you'll face along the way.

47:20Dr. Susan Hudson: Before we go, remember, this podcast is intended for education and entertainment only.

47:25Dr. Carrie Bedient: While we are fertility doctors, we are not your fertility doctors.

47:28Dr. Susan Hudson: Nothing we discuss should replace medical advice from your own physician who knows your individual history and circumstances. Thanks for listening. Bye! This podcast is sponsored by Receptiva DX. When fertility questions remain unanswered, Receptiva DX helps reveal why. Trusted by fertility specialists for over a decade, Receptiva DX identifies inflammatory changes in the uterine lining associated with endometriosis and other conditions that may interfere with implantation and pregnancy. From unexplained infertility, recurrent pregnancy loss, or simply undiagnosed pain, Receptiva DX helps women and their physicians make more informed treatment decisions and move forward with confidence.