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Scheduled 1st RE Apt


Forum: Trying to Conceive with Medical Assistance

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  • 1 Post By *JenJen*
  • 1 Post By KMH

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  #1  
June 25th, 2013, 04:26 PM
BabyBirdies's Avatar over the rainbow?
Join Date: Apr 2010
Location: Manhattan :)
Posts: 1,850
Well, I worked up the nerve to do it! I called the place that we decided on and were able to schedule for Thursday, July 11. Hopefully it'll be a good process.

The only annoying thing is that I called my insurance company and am now a) confused about how much they will cover and b) annoyed to discover that they somehow got out of at least part of the NY state mandated stuff. They said they cover diagnosis but not treatment (whatever that means), and no fertility medication. Too bad NY state says that if the plan has a drug benefit (which ours does) it should cover fertility medication as well. So what gives? No idea. Feeling a little down about that, and unsure how this will turn out $$ wise!

Still, moving forward - a little bit, at least!
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Thanks Jaidynsmum for the siggy!
My fertility blog: Only Infertile



NTNP since March 2012, TTC since August 2012, HSG = one blocked tube, SA = normal, 1st RE 7/11 - took a zillion tests, 2nd RE appt = Tubal issue with PCOS tendencies, possible polyp, August 2013 - possible polyp, September 2013 - new job, insurance change! January 2014 - new insurance, March 2014 - new RE appointment, then surprise BFP!

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  #2  
June 25th, 2013, 04:30 PM
ChiChica's Avatar Mega Super Mommy
Join Date: Jan 2013
Location: Chicago
Posts: 1,251
Good luck! Maybe they meant that they didn't cover treatment and medicine without preauthorization? I'm in Illinois, and we have a similar legal mandate. My insurance company covered all of my testing, monitoring, and clomid and/or femera without preapproval. In order to get "treatment" covered (e.g. IUI or injectable meds), you had to get preapproval. That just required the doctor sending a letter saying that we had been off birth control and having unprotected sex for 1 year. Hopefully the RE's financial adviser can help you navigate the insurance issues. FX for you.
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~Lindsay~

Expecting baby #1 through IUI with Follistim




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  #3  
June 25th, 2013, 05:10 PM
Lucy S.'s Avatar POAS addict
Join Date: Sep 2012
Location: Bay area CA
Posts: 6,046
I'm in CA and our legal mandate doesn;t help much at all.
My insurance covers diagnosis but not treatment- basically blood work and testing like HSG. but not IUI or IVF or the u/s they do for them.
I do have some medication coverage but most plans have none.
CA: Employers decide if they will provide the following benefits to their employees: diagnosis, diagnostic testing, medication, surgery, and Gamete Intrafallopian Transfer (GIFT).


But ya, how can NY get around the medication when RESOLVEs latest has it mandated like you said?
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Lucy
Due with #3
10 IUIs= one confirmed /IVF= BFN / FET= / FET2= Baby!
My blog


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  #4  
June 25th, 2013, 05:16 PM
*JenJen*'s Avatar impatiently waiting
Join Date: Aug 2008
Location: west, but east. south, but not north.
Posts: 7,756
good luck! If you call fertility lifelines, they'll actually tell you exactly what your plan covers. It's very helpful to know!
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2006-2013 6+ years of NTNP, TTC, TTCMA, Losses, Surgeries, and Diagnoses.
RPL and Genetic Tests came back 100% normal | Endo, PCOS, severe MFI
Multiple early losses between 3 and 8 weeks.

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  #5  
June 25th, 2013, 06:24 PM
KMH KMH is offline
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Join Date: Sep 2008
Location: right of center
Posts: 19,128
Ditto. Call Fertility Lifelines (1-866-LETS-TRY) and they will explain everything for you. They also sent it to me in writing. They also have nurses and counselors you can speak with if you have any questions or just someone to vent to. Good luck!
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IVF babies Claire (4), Abigail (2) and George (2)

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  #6  
June 26th, 2013, 06:19 AM
kayakr's Avatar Persuaded by POAS’ers
Join Date: May 2011
Location: Midwest
Posts: 3,751
Ohio is the same. They are suppose to cover fertility treatments but the employer can still elect to not have that as part of their insurance benefits. Mine paid for diagnostic but not treatments or medication. Medication seems to be where most of the cost goes unless you get to IVF.
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Gretchen
Me (43) DH(33) 12 years together - ttc our first together-I have 14yr old DS
Cycles 1-6 = BFN
Cycle 7 SA results abnormal morphology 2%, 50 mg clomid = BFN
Cycle 8 sonogram normal 50 mg clomid + trigger = BFN
Cycle 9 SA results abnormal morphology and motility. Count 200 mill, 100mg clomid + trigger = BFN
Cycle 10 natural = BFN
Cycle 11 hsg tubes clear, natural + trigger+IUI = BFN
Cycle 12 repronex + trigger + 2 IUI = BFN
Cycle 13 natural ovaries to stimulated for more meds = BFN
Cycle 14-22 natural cycle with Acupuncture and planning ivf/icsi/DE = ALL BFN
Cycle 23 Clomid 50 mg & Progesterone = BFN
Cycle 24 Natural = BFN
Cycle 25 BCP, SA result 7% morphology = BFN
Cycle 26 BCP and Lupron preparing for IVF
Cycle 27 IVF Acupuncture, DE Retrieval April 7, Transfer April 12 =
7 eggs retrieved, 3 fertilized, 2 transferred - zero snow babies
BETA # 1 16DPO or 11dp5dt = 569
BETA # 2 19 DPO or 14dp5dt = 1078
BETA # 3 22DPO or 17dp5dt = 2414 TWINS!
BETA # 4 30DPO or 25dp5dt = 12,685 6weeks 3days 2 heartbeats! 114 & 116
Clayton and Colton Born @ 34 weeks 11/22/13
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  #7  
June 26th, 2013, 08:04 AM
Lash's Avatar Platinum Supermommy
Join Date: Jun 2006
Location: North Texas
Posts: 17,679
There are tons of ways for them to opt out of what to cover. Notice that your plan in New York excludes IVF coverage, which may mean that since those meds are part of IVF, then they aren't covered and are considered optional. Also where is your company located and where do they purchase insurance? If their home office is say in Ohio, technically they follow Ohio law on insurance, not New York

NEW YORK
1990, 2002
NY S.B. 6257-B/A.B. 9759-B
NY Insurance Law Sections 3216 (13), 3221

Definition of Infertility/Patient Requirements

Prohibits the exclusion of coverage for the diagnosis and treatment of a correctable medical condition, solely because the condition results in infertility.
The law abides by the ASRM definition of infertility. ASRM defines infertility as the inability to achieve a pregnancy after trying for 12 months if you are under 35 and 6 months if you are over 35.
Coverage is provided to patients 21 to 44 years old.
Patients must be covered under their insurance policy for at least 12 months before receiving infertility coverage.
Coverage

Group policies must provide diagnostic tests and procedures that include:

hysterosalpingogram;
hysteroscopy;
endometrial biopsy;
laparoscopy;
sono-hysterogram;
post coital tests;
testis biopsy;
semen analysis;
blood tests and
ultrasound
Every policy that provides for prescription drug coverage, shall also include drugs (approved by the FDA) for use in the diagnosis and treatment of infertility.
Exceptions

Excludes coverage for IVF, GIFT, and ZIFT; reversal of elective sterilizations; sex change procedures; cloning or experimental medical or surgical procedures.
Employers who self-insure are exempt from the requirements of the law.

The laws were amended again in 2011 by N.Y. laws, Chap. 598 to require every policy that provides coverage for prescription fertility drugs and requires or permits perscription drugs to be purchased through a network participating mail order or other non-retail pharmacy to provide the same coverage for perscription fertility drugs that are purchased from a network participating non-mail order retail pharmacy provided that the network participating non-mail order retail pharmacy agrees in advance to the same reimbursement amount and the same terms and conditions that the insurer has established for a newtork participating mail order or other non-retail pharmacy. The policy is prohibited from imposing additional fees, co-payments, co-insurance, deductibles or other conditions on any insured person who elects to purchase prescription fertility drugs through a non-mail order retail pharmacy
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"I will make it through this because it is for her and for her, I will do anything. I am not brave, I am not strong, I am just Rhiannon’s mom". Our TTC/Adoption/Pregnancy Blog: Jump Over The Rainbow

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  #8  
June 26th, 2013, 10:52 AM
JessicaW's Avatar Super Mommy
Join Date: Aug 2011
Location: Central Jersey
Posts: 754
New Jersey has a mandate covering fertility treatment up to four IVF cycles. However, if your employer "self-insures", they are exempt from state insurance regulation. I believe the self-insurance loophole exists in other states. Employers with fewer than 50 employees are also exempted from the NJ mandate. Typically, large employers self-insure. So if you want to be covered by the NJ mandate, you have to work at a place with more than 50 employees but not so many that it self-insures!

When an employer self-insures, that means that they pay directly for your medical care and they also receive your premium payments. They hire a Blue Cross, Cigna, Aetna or whatever to administer the plan, i.e. process the claims, run the call centers, etc., but the actual money that pays for your care comes from your employer. Because you are always dealing with an insurance rep whether your employer self-insures or not, you won't know unless you ask. My employer does not self-insure but my husband's employer does. So I am covered under the mandate but would not be if I went on my husband's plan.

Also, if I work in New Jersey but my employer is headquartered in another state that does not have a mandate, I might not get coverage under the mandate. Also, if I work in New Jersey but the insurance policy is somehow based in another state, that could also create problems.

On another topic, I had never heard of Fertility Lifelines. Maybe put that in one of the pages Jen is working on...
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Me: 36 DH: 33
PCOS
DD: July 2012

TTC#2:
May-June 2013: Follistim + IUI = overstimulated, cycle cancelled
July 2013: Follistim + IUI = m/c at 4.5 weeks
August-Sept 2013: BCPs then IVF = freeze-all due to OHSS risk
October 2013: Natural cycle = BFN
November 6, 2013: Day 1 !!!!
November 24, 2013: Transferred one thawed euploid male embryo
November 29, 2013: BFP!
August 12, 2014: Cautiously hoping for this due date

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  #9  
June 26th, 2013, 02:13 PM
BabyBirdies's Avatar over the rainbow?
Join Date: Apr 2010
Location: Manhattan :)
Posts: 1,850
It's a big university, so maybe they self-insure? I'm sure they are headquartered in NY, at least.

Going to call Lifelines either later today or tomorrow. So thankful for all the wonderful advice!!
__________________

Thanks Jaidynsmum for the siggy!
My fertility blog: Only Infertile



NTNP since March 2012, TTC since August 2012, HSG = one blocked tube, SA = normal, 1st RE 7/11 - took a zillion tests, 2nd RE appt = Tubal issue with PCOS tendencies, possible polyp, August 2013 - possible polyp, September 2013 - new job, insurance change! January 2014 - new insurance, March 2014 - new RE appointment, then surprise BFP!

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