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Infertility coverage 101: Understanding your fertility benefits

Navigating infertility treatment can be overwhelming.

Whether you’re seeking treatment for a medical condition or need help conceiving, the fertility journey is often complex.

The acronyms alone can feel like an entirely new language: intrauterine insemination (IUI), in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), egg retrieval (ER). Then add on top the emotional highs and lows of the family planning process, and it’s easy to see how fertility patients can feel bogged down.

Healthcare costs and insurance coverage can add yet another layer of complexity to the process. But we want you to know you don’t have to figure it out all on your own.

If you’re considering using fertility services, a good first step is to call your insurance carrier. They’ll be able to tell you what kind of fertility coverage is available under your health plan. Some employers provide additional benefits for adoption and surrogacy, so be sure to check with your company’s human resources department, as well.

It may help to think of this as an information-gathering phase. You likely have a lot of questions, and we want to help you find the answers you need to plan your next steps.

What benefits do you have?

If you’re a Blue Cross and Blue Shield of North Carolina (Blue Cross NC) member, you can find your benefit booklet by logging in to Blue Connect. Look for the section titled Family Planning. Under Infertility Services, you’ll see a list of services your insurance policy covers. Remember: Even if fertility services are covered by your plan, you will still have to meet your annual deductible and out-of-pocket expenses.

It’s always a good idea to call your insurance company to learn more about your benefits. You can find the benefits phone number on the back of your card.

Here is a list of questions you may want to ask:

  • Does my plan cover the cost of the labs and procedures used to diagnose infertility?
  • Which fertility treatments does my plan cover?
  • Which fertility treatments does my plan not cover?
  • Do I need prior authorizations for my health plan?
  • Is there a lifetime maximum number of cycles or procedures allowed?
  • Is my preferred clinic in-network (do they have participating providers with my insurance plan)?

If you don’t yet have a clinic picked out, read on for tips on finding a doctor for your fertility care.

Did you know?

It’s easy to feel alone when dealing with fertility struggles, but infertility is not uncommon. According to the CDC, about one in five couples with no previous births experience infertility.

Infertility can often be treated with medicines, surgery or assisted reproductive technology.

Choosing a fertility clinic

At the time this article is published, Blue Cross NC members don’t need a referral to see a specialist. That means you can make an appointment to see a fertility specialist at any time, without having to go through your primary care provider.

One way to find an in-network doctor or clinic is to use our Find Care tool. Start by clicking on “Individuals, Families & Groups,” then choose your plan and click on “Find a Doctor or Facility.” The tool allows you to search by the type of specialist you want to see. In this case, you’ll likely be looking for a reproductive endocrinologist (RE), which is an OB/GYN who specializes in fertility. This tool is available to non-members, as well, who are searching for doctors in North Carolina.

Once you’ve chosen your provider, it’s a good idea to double check with your insurance provider to confirm that the provider is in-network.

When choosing a clinic or doctor, you may also want to consider:

  • What are the clinic’s pregnancy success rates?
  • Are their providers board certified reproductive endocrinologists?
  • Do they offer the treatment options I’m looking for?
  • Do they have a waiting list or appointment openings that fit with my timeline? 
  • Are the staff helpful and friendly?
  • Is it easy to communicate with them?
  • Do they provide culturally sensitive care, if this is important to me?

It may sound obvious, but you should also listen to your instincts when you meet a doctor at your initial consultation. Do you like them? Do you feel comfortable asking questions and raising concerns? Your RE will play a big role in your family building journey, so it’s important that you connect well with them.

Navigating your pharmacy benefits

In addition to the procedures involved in fertility care, you may also need medications. Not all fertility drugs are covered by insurance. Unfortunately, these medications can be expensive.

To check whether your prescriptions are covered under your plan, you can log in to Blue Connect and go to the Prescriptions page. Click on Find a Drug, then Search for Prescription Drugs. You can also call us using the pharmacy number on the back of your insurance card.

While the cost of fertility medications can be high, generics will typically cost less than brand-name drugs. Once you know which medications you need, ask your doctor if there is a generic version you can take.

Something else to consider is the different types of medications available. For example, a medication commonly used in an IVF cycle is progesterone. Progesterone comes in several forms, including an injection, a pill and a vaginal suppository. Your insurance plan might cover one form but not another, so make sure to ask both your doctor and your insurance provider about the types of medications that make the most sense for you.

For medications that insurance doesn’t cover, you can always use an app like GoodRx or check the manufacturer’s website to find discounts and rebate programs. You can also call around to different pharmacies to find the best price. You may need to get these medications from a specialty pharmacy.

Summary

Everyone’s journey to parenthood is unique and personal, but for everyone dealing with infertility, family planning can be an overwhelming but exciting time.

We know that the family-building journey can bring up a lot of emotions. Some people may experience anxiety, guilt, stress, and even grief. If you feel you need additional emotional support as you seek fertility care, here are our tips on how to find a therapist.

We’re also here to help every step of the way as you navigate your insurance benefits.

We wish you the best on your fertility journey!

Kia Williams, MD, MSPH
Kia Williams, MD, MSPH

Associate Medical Director

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Disclosures:

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) offers several decision-support tools to aid you in making decisions around your health care experience. These tools are offered for your convenience and should be used only as reference tools. You should consult your own legal counsel, tax advisor or personal physician as applicable throughout your health care experience.

Deductibles, coinsurance, limitations and exclusions apply to coverage. Further details of coverage, limitations and exclusions, and terms will be provided in your Benefit Booklet.

GoodRx is not affiliated with Blue Cross NC and doesn’t offer Blue Cross Blue Shield products.