Pre Authorization IVF Meds

[Anonymous]

Hello! I am dealing with a frustrating situation where I am told that SGF (in Arlington) obtained prior authorization for IVF medication, while my insurance saying they never received a request, and my pharmacy saying I have no coverage. Any idea on what I should do? $8k at stake

[Anonymous]

The number of frustrating hours spent on the phone with a fertility clinic, insurance provider, and pharmacies is actually unbelievable. My only advice is keeping calling, keep pushing, keeping asking questions. I've never needed prior auth for drugs, because they don't come from the clinic, so start with the insurance company to better understand what's happening.

You must be on a pretty high dose protocol. I got quotes of $8K-9K when on high dose protocols (think 450 of gonal-f), but wouldn't buy everything prescribed all at once. These pharmacies can ship overnight, so you can get your first 7 days or so worth of meds and see how you do and then order what you need next. I found SGF was very generous with their prescriptions, and I ended up with extra meds when I ordered everything all at once (which can mean money wasted).

Good luck. I don't think folks talk enough about the administrative side of fertility treatment. I think I shed more tears in sheer frustration dealing insurance or pharmacies or clinics than any other part of this journey.

[Anonymous]

My clinic uses Cloud Rx and they helped get authorizations although we were still delayed by a couple of days getting full order of meds. We had to pay out of pocket for 2 days but getting reimbursed by prime therapeutics.

[Anonymous]

Thank you so much for your feedback! I tremendously appreciate all your advice! Yes I am on a high protocol (even though I’m older, 41) but my doctor wants to try it out and see how I respond. And yes the administrative part of fertility treatment is not talked enough about and it adds stress to an already stressful process!

Anonymous wrote:The number of frustrating hours spent on the phone with a fertility clinic, insurance provider, and pharmacies is actually unbelievable. My only advice is keeping calling, keep pushing, keeping asking questions. I've never needed prior auth for drugs, because they don't come from the clinic, so start with the insurance company to better understand what's happening.

You must be on a pretty high dose protocol. I got quotes of $8K-9K when on high dose protocols (think 450 of gonal-f), but wouldn't buy everything prescribed all at once. These pharmacies can ship overnight, so you can get your first 7 days or so worth of meds and see how you do and then order what you need next. I found SGF was very generous with their prescriptions, and I ended up with extra meds when I ordered everything all at once (which can mean money wasted).

Good luck. I don't think folks talk enough about the administrative side of fertility treatment. I think I shed more tears in sheer frustration dealing insurance or pharmacies or clinics than any other part of this journey.

[Anonymous]

Shouldn’t SG have documentation of the prior authorization approval? If so, they should give you a copy (ask for this) and then resubmit to insurance so you can get covered.

[Anonymous]

Sometimes fertility meds aren't covered under a pharmacy plan but are covered under the medical plan. When I did IVF, my meds were billed directly to the medical insurance. It took a bit of time on the phone and some cooperation from the pharmacy but I recommend you give your insurance a call. Some insurance plans even have specific fertility specialists to help navigate these kinds of questions.

[Anonymous]

I don't have any coverage (thanks Tricare!) So super easy for me personally. Just $$$%