Comprehending Costs

Treatment Costs

Along with our scientific, clinical, and patient service teams focused on your success, we also have many financial counselors who are a part of your care team – helping to answer the many questions about comprehending costs and insurance coverage. We can help you navigate the complexities and provide basic guidelines of the financial process. Some plans require referrals or authorizations so it’s suggested that you check your infertility benefits under your specific plan.

RMAPA participates in several insurance plans, including:

  • Aetna
  • Cigna
  • Capital Blue Cross
  • Keystone Central
  • Highmark Blue Sheild
  • Horizon Blue Cross and Blue Shield
  • Oxford Health Plan
  • United Health Care
  • First Priority LifeKeystone East
  • Independence Blue Cross
  • Personal Choice
  • AmeriHealth
  • Geisinger Health Options (Non-St. Luke's Employee Plans)
  • Populytics (LVHN Employee Plans)
  • UMR (Sands Employees)

Infertility benefits vary from patient to patient and from provider to provider. We’ve put together a few key points about insurance coverage by major plans to help you manage expectations of coverage. The information provided is for informational purposes only and is not a commitment of coverage. Below you will find a helpful list of important questions to ask your insurance provider. Make sure to document the name of the person you spoke with, as well as the time and date of the call, for future reference.

 

Questions for your provider:

  • Which of the following are covered by my current benefits:
    • ​Diagnostic testing
    • Imaging related to ovarian stimulation for In Vitro Fertilization (IVF) or egg freezing
    • In Vitro Fertilization (IVF) — how many cycles?
    • Intrauterine insemination (IUI) — how many cycles?
  • Fertility medications—if yes, is there a total monetary medication “allowance”, a maximum number of vials, or other product limitations?
  • Are there any limitations to my benefits, such as age, medical conditions, or prior cycles?
  • Can you please provide a written explanation of my benefits?

Navigating the world of fertility benefits can be confusing and overwhelming–to speak to an RMAPA Financial Counselor about how to optimize your coverage, call us at (610) 820-6888 or make an appointment below.



Coverage Details


Waiting Time for Authorization

Varies greatly depending upon your plan, please ask your RMAPA financial coordinator for more information.

Basic Requirements for ART/IVF Coverage

Not Applicable

General Rules and Requirements

Many plans contain general infertility benefits however clinical criteria varies.

Plans may require patients meet “lesser before greater” treatment criteria before moving to advanced treatment.

Same sex or single female patients are usually not considered infertile.

Patients can work with their RMANJ financial coordinator to determine specific coverage.

Pregnancy Monitoring

Not Applicable

Genetic Testing (PGD)

Not Applicable

Waiting Time for AuthorizationApproximately 5-7 business days from submission of your paperwork. Authorizations cannot be backdated.
Basic Requirements for ART/IVF CoverageUnmedicated Day-3 blood work within 6 months to 1 year based on age.

Day 3 FSH over 19 may void benefits, a random elevated FSH will not affect coverage. 2 abnormal SA’s required at least 2 weeks apart for ICSI.

Outside results acceptable. Embryo and oocyte banking are not allowed.
General Rules and RequirementsUnmedicated Day-3 blood work within 6 months to 1 year based on age. Clomid/Letrozol with or without IUI cycles are billed per visit.

FSH/IUI and all ART procedures billed globally (your insurance is billed 1 code that includes most services for the cycle.) If major procedures are not covered, cycle monitoring and other related services are not covered.

Most Aetna plans require cycle authorization before medication authorizations. Medication plans may approve standard doses; additional authorizations for refills may be required. Plan may require patients meet “lesser before greater” treatment criteria for advance treatment. 
Pregnancy Monitoring

Limited to 3 pregnancy monitoring visits unless additional visits are deemed medically necessary.

Genetic Testing (PGD)Patient responsible for confirming coverage for PGD. Coverage for some single gene defects only and some specific hereditary disease. If PGD covered, RGI is the only participating lab in network for PGD.

PGD for aneuploidy is not covered regardless of which lab is used. Foundation For Embryonic Competence is non-par. Payment in full is required before treatment.

RMAPA finance can submit claims to insurance per patient request in case partial reimbursement is available.
Waiting Time for AuthorizationApproximately 7-10 business days from submission of your paperwork.
Basic Requirements for ART/IVF Coverage

No stated limits or requirements.

General Rules and Requirements

Plans may require patients meet “lesser before greater” treatment criteria before moving to advanced treatment.

Pregnancy Monitoring

No stated limits or requirements.

Genetic Testing (PGD)

PGD considered experimental, coverage is rarely provided.

Patient responsible for confirming coverage for PGD.

Foundation for Embryonic Competence is non-par. Payment in full is required before treatment.

RMAPA can submit to insurance per patient request in case partial reimbursement is available.

Waiting Time for AuthorizationApproximately 7-10 business days from submission of your paperwork.
Basic Requirements for ART/IVF CoverageSome plans may have limited coverage for IUI treatment cycles. Majority of plans do not have coverage for IVF/FET/Donor/GC/Surrogate services.
General Rules and RequirementsPlans with coverage may require patients meet “lesser before greater” treatment criteria before moving to advanced treatment.
Pregnancy MonitoringNo stated limits or requirements.
Waiting Time for AuthorizationApproximately 7-10 business days from submission of your paperwork.
Basic Requirements for ART/IVF CoverageMost plans do not have coverage for treatment.
General Rules and RequirementsPlans with coverage may require patients meet “lesser before greater” treatment criteria before moving to advanced treatment.
Pregnancy MonitoringNo stated limits or requirements.
Waiting Time for AuthorizationApproximately 7-10 business days from submission of your paperwork.
Basic Requirements for ART/IVF CoverageSome plans may have limited coverage for IUI treatment cycles. Majority of plans do not have coverage for IVF/FET/Donor/GC/Surrogate services.
General Rules and RequirementsPlans with coverage may require patients meet “lesser before greater” treatment criteria before moving to advanced treatment.
Pregnancy MonitoringNo stated limits or requirements.
Waiting Time for AuthorizationApproximately 4-7 business days from submission of your paperwork. Predetermination letter may require 30-days.
Basic Requirements for ART/IVF CoverageClinical history including physician notes, blood work, day-3 FSH, semen analysis, saline sonogram or HSG reports.
General Rules and RequirementsMost plans require clinical history including physician notes, blood work, day-3 FSH, semen analysis, saline sonogram or HSG reports before authorization is issued. Plan may require patients meet “lesser before greater” treatment criteria for medications, even if procedures have already been approved.
Pregnancy MonitoringLimited to 3 pregnancy monitoring visits unless additional visits are deemed medically necessary.
Genetic Testing (PGD)PGD considered experimental, coverage is rarely provided. Patient responsible for confirming coverage for PGD. Foundation for Embryonic Competence is non-par. Payment in full is required prior to treatment. RMAPA can submit to insurance per patient request in case partial reimbursement is available.
Waiting Time for Authorization

Approximately 4-7 business days from submission of your paperwork.

Predetermination letter may require 30-days.

Basic Requirements for ART/IVF Coverage

Clinical history including physician notes, Day-3 FSH, within 6-12 months based on patient age, AMH, BAFC, SA within 12 months.

General Rules and RequirementsHistory including Day 3 FSH within 12 months based on patient age, AMH, BAFC.

SA will likely be required for most cycle types. FSH/IUI and all ART procedures billed globally. If major procedures are not covered, cycle monitoring and other related services are not covered.

Authorizations can not be backdated. If authorization is not requested on or before cycle start date, cycle will not be authorized.

Some Oxford plans will count clomid IUIs towards lesser before greater criteria.

Oxford does require medical director review for additional IUI cycles if the first 3-4 are unsuccessful. This may delay response time for authorization by 2-3 business days.

Oxford will not allow IUI with inject-able medications unless the patient fails clomid. Requests for COH IUI will be reviewed on a case to case basis. Oxford typically allows a maximum of 4 IUI cycles for patients 37 and under, 2 IUI cycles for patients 38 or 39 and only 1 IUI cycle for pts 40 and over.
Pregnancy Monitoring

Limited to 3 pregnancy monitoring visits unless additional visits are deemed medically necessary.

Genetic Testing (PGD)

PGD considered experimental, coverage is rarely provided.

Patient responsible for confirming coverage for PGD.

Foundation for Embryonic Competence is non-par. Payment in full is required before treatment.

RMAPA can submit to insurance per patient request in case partial reimbursement is available.

Waiting Time for AuthorizationApproximately 15 - 20 business days from submission of your paperwork.
Basic Requirements for ART/IVF Coverage

Clinical history including physician notes, Day-3 FSH, within 6-12 months based on patient age, AMH, BAFC, SA within 12 months.

General Rules and Requirements

Most plans require MD notes, day 3 FSH within 12 months and saline sonogram or HSG before authorization can be issued.

Pregnancy Monitoring

No stated limits or requirements.

Genetic Testing (PGD)

PGD considered experimental, coverage is rarely provided.

Patient responsible for confirming coverage for PGD.

Foundation for Embryonic Competence is non-par. Payment in full is required before treatment.

RMAPA can submit to insurance per patient request in case partial reimbursement is available.

Waiting Time for AuthorizationApproximately 7-10 business days from submission of your paperwork.
Basic Requirements for ART/IVF CoverageSome plans may have limited coverage for IUI treatment cycles. Majority of plans do not have coverage for IVF/FET/Donor/GC/Surrogate services.
General Rules and RequirementsPlans with coverage may require patients meet “lesser before greater” treatment criteria before moving to advanced treatment.
Pregnancy MonitoringNo stated limits or requirements.
Waiting Time for AuthorizationApproximately 7-10 business days from submission of your paperwork.
Basic Requirements for ART/IVF CoverageSome plans may have limited coverage for IUI treatment cycles. Majority of plans do not have coverage for IVF/FET/Donor/GC/Surrogate services.
General Rules and RequirementsPlans with coverage may require patients meet “lesser before greater” treatment criteria before moving to advanced treatment
Pregnancy MonitoringNo stated limits or requirements.
Waiting Time for AuthorizationApproximately 7-10 business days from submission of your paperwork.
Basic Requirements for ART/IVF CoverageSome plans may have limited coverage for IUI treatment cycles. Majority of plans do not have coverage for IVF/FET/Donor/GC/Surrogate services.
General Rules and RequirementsPlans with coverage may require patients meet “lesser before greater” treatment criteria before moving to advanced treatment.
Pregnancy MonitoringNo stated limits or requirements.
Waiting Time for AuthorizationApproximately 7-10 business days from submission of your paperwork.
Basic Requirements for ART/IVF CoverageSome plans may have limited coverage for IUI treatment cycles. Majority of plans do not have coverage for IVF/FET/Donor/GC/Surrogate services.
General Rules and RequirementsPlans with coverage may require patients meet “lesser before greater” treatment criteria before moving to advanced treatment.
Pregnancy MonitoringNo stated limits or requirements.
Waiting Time for Authorization

Approximately 7-10 business days from submission of your paperwork.

Basic Requirements for ART/IVF CoverageSome plans may have limited coverage for IUI treatment cycles. Majority of plans do not have coverage for IVF/FET/Donor/GC/Surrogate services.
General Rules and Requirements

No stated limits or requirements.

Pregnancy Monitoring

No stated limits or requirements.

Genetic Testing (PGD)

PGD considered experimental, coverage is rarely provided.

Patient responsible for confirming coverage for PGD.

Foundation for Embryonic Competence is non-par. Payment in full is required before treatment.

RMAPA finance can submit claims to insurance per patient request in case partial reimbursement is available.

Basic Requirements for ART/IVF CoverageSome plans may have limited coverage for IUI treatment cycles. All plans do not have coverage for IVF/FET/Donor/GC/Surrogate services.
General Rules and RequirementsNo stated limits or requirements.
Pregnancy MonitoringNo stated limits or requirements.
Waiting Time for AuthorizationApproximately 7-10 business days from submission of your paperwork.
General Rules and RequirementsNo stated limits or requirements.
Pregnancy MonitoringNo stated limits or requirements.
Basic Requirements for ART/IVF CoverageCovered person must have been covered under this health plan for a minimum of 24 months