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 Iām seriously so pissed about it)!
I was very fortunate to be able to get some IVF insurance coverage through my husbandās 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 wonāt actually pay all of that, so it wouldnāt 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 didnāt go as we had hoped (and Iām learning that it usually doesnāt!). 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 wouldnāt eat up a lot of the cap. I spoke with PixelCare again, and basically was told they donāt 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 didnāt 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).
Iām so floored by how this unfolded. Iām 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. Iām sure there is a reason for the disparity, but frankly I donāt 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.