How Fertility Medication Fits Into Benefit Utilization

Knowing which benefits will be covered and which will be out of pocket gives you a complete understanding of how to best use your insurance benefit for your first attempt at infertility treatment. This will help you under the cost of possible subsequent attempts, should the first attempt prove to be unsuccessful or if you decide to have another child in the future.

With constant healthcare changes, it has become more common for infertility medications to be included in your lifetime maximum insurance benefits. While a lifetime benefit of $15,000 or more may seem like a lot, it may be insufficient to cover the costs of even one IVF attempt within the realm of fertility treatment. Infertility medications are often billed to insurance at a significantly higher rate than when paying cash (paying out of pocket) for your medications, not unlike what you have experienced when looking at your medical benefits.

The price discrepancy is due to contracted provider rates between insurance companies, medical providers and pharmacies. How this affects you is that medications may utilize a significant amount of your infertility benefit even before you begin the process of your infertility medical treatment. This may leave you with substantial and unexpected out-of-pocket expenses when undergoing the medical portion of your treatment.

The Good News

As a pharmacy that focuses on fertility, apthorp receives discounts from the drug companies which we pass directly on to our patients. It is very common for one’s medications to be included in your lifetime fertility insurance maximum and therefore, you’ll want to ensure that you are paying the lowest price possible for them while using your finite benefits toward actual medical treatments. You can save 50% or more on your fertility medications if you pay out of pocket vs using your limited insurance benefits to cover the costs.

Pharmaceutical manufacturers working with organizations that support specific local pharmacies that are recognized as fertility specialty pharmacies are provided with heavily subsidized discounts for self-pay (out of pocket) prescriptions. We also have access to patient support programs that can dramatically reduce the cost of fertility medications. These base discounts are offered to all fertility patients and all patients can apply for additional discounts through the manufacturer and local pharmacy-supported supplemental discount programs. These discounts depending on the drug manufacturer, are either point of sale discounts, which means that the discounts are applied when your medication is purchased or rebate programs, that you need to pay the entire amount upfront and file for a rebate later. This allows you to preserve all of your infertility benefits for essential medical treatment if more advanced treatment options or additional treatment attempts are needed to achieve a successful pregnancy.

Maximizing Utilization Of Your Fertility Benefits

Accessing and navigating your fertility insurance benefit can seem fairly straightforward, but there are important considerations when deciding how to best use your benefits. After contacting your insurance company and obtaining a general description of your infertility benefit, it is essential to note your lifetime maximum benefit, also known as your cap. This dollar amount is all that will be covered by your insurance company for your journey towards having a baby. There are questions that you will want to ask your insurance company that will be essential in helping you better utilize your fertility benefit.

How To Access Drug Discount Programs

Thankfully the process of accessing drug discount programs for fertility medications is simple. Our team at apthorp are experts at helping you access a range of discount programs. We can handle the application for initial discounts and provide you with assistance to access supplemental discount programs. Your fertility center patient financial coordinator can also provide you with information on how to access supplemental discount programs.

Additional Savings For Those Who Need Financial Assistance

We are committed to providing our fertility patients with a wide range of additional financial options to help them achieve their family dreams. Through funding from pharmaceutical manufacturer Organon, apthorp can offer savings for those self-pay (out of pocket) patients who need help paying for their fertility medications. Savings are based on income and financial need and qualifying patients can save up to 75% on Follistim, Ganirelix and Pregnyl.