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Fertility coverage and what your insurance may provide but not be telling you…

Maneuvering through the maze that are infertility benefits coverage can be a huge hurdle all on its own. Use this insider's information to help you find out what you need to know...

Maneuvering through the maze that is infertility benefits coverage can be a huge hurdle all on its own. Use this insider’s information to help you find out what you need to know…


Over and over I’ve come across so many couples already suffering with the difficulties of Infertility, only to be lost when it comes to finding out what their insurance company actually covers.  I’ve touched on this topic before:

Our Insider’s Guide to paying for an IVF

But what about I offer you some suggested questions you can ask your insurance company when you try and find out your actual coverage.  Remember though, a quotation of benefits does not guarantee payment by your insurance company.

Ok, ready? Here goes:


  1. What are my fertility benefits?  You need to make sure that you’re talking to the correct department! You’d be amazed how they will give you the run around because the representatives don’t even know what department Infertility falls under.  Usually medical and then a subset of that will be Infertility benefits.
  2. Do I need a pre-authorization to have diagnostic tests run related to Infertility? Always ask this first! You’d be amazed how this step is sometimes overlooked and the patient then gets stuck with the entire bill.  Don’t let this be you!
  3. Do I need a referral to obtain fertility treatments or to see a fertility specialist such as a Reproductive Endocrinologist?
  4. Do I have a copay or a deductible for fertility treatments?
  5. Are there any requirements which must be met before my fertility benefits become effective? Some examples might be your blood hormone levels might have to fall within a certain range (FSH below 20), certain number of of IUI’s before IVF can be attempted, documented medical history of infertility?
  6. Do I have an annual or lifetime maximum benefit for Infertility? There might be a maximum number of allowed attempts for an IUI and/or an IVF, what is the maximum amount of dollars payable in total per year/per lifetime.


  1. What diagnostic testing is covered?  Remember that you and your spouse will have to have several tests performed to evaluate your fertility health.  i.e. Diagnostic prenatal screening labs (Hep. B, Hep, C, HIV, etc.), Progesterone and Estrogen levels? FSH, LH, TSH, Prolactin Levels, Semen analysis, Hysterosalpingogram (HSG), Saline Infusion Sonohysterogram (SIS), endometrial biopsy, ultrasound- ICD 10 code- 231.41 (fertility testing).
  2. Do you cover medication administration education (mixing medications and injections)?
  3. What treatments or procedures related to treatments are covered? Ultrasound? Medical Fertility Therapy? IUI/Artificial Insemination? IVF? Intracytoplasmic Sperm Injection (ICSI)?, Cryopreservation? Assisted Hatching? Preimplantation Genetic Diagnosis (PGD)?
  4. Are prenatal screening (infectious diseases) and genetic disease carrier screening tests covered?
  5. Are lab services covered at the RE’s lab or are you restricted to certain lab/facilities in your network?
  6. What treatments are excluded?
  7. Are donor sperm and/or donor egg options covered?
  8. Is cystic fibrosis carrier screening covered?
  9. CPT codes 83894, 83896, 83912, 83901 and ICD 10 codes- Z14.1, Z31.430, Z31.440


  1. If medications are covered, must they be purchased from a specific pharmacy?
  2. What about Clomiphene Citrate (Clomid)?
  3. Letrozole?
  4. Gonadotropin Injectibles (FSH or LH medications: Follistim, Gonal-F, Bravelle, Luveris, Menopur and others)?
  5. GnRH Agonists/Antagonists (Lupron, Ganirelix, Cetrotide and others?
  6. Is Estrogen covered? In what form- patches or tablets?
  7. Is Progesterone covered and if so how is it administered? Prometrium tablets, suppositories, injections, and others?


Hopefully this helps answer some of the many questions you may have.  Any others, please feel free to reach out to me either on the community board or directly


***These questions are only meant as a guideline and don’t represent a complete list of all possible questions that should be asked to fully understand your insurance coverage.  Be aware that all services and expenses may not be covered by your insurance policy.***


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