Fed Ins / Dr. Question/course of action advice

[Anonymous]

Sorry to ask another fed question, but I just could use some advice on the proper course of action. Background is TTC #2 for 15 months. Have BCBS PPO through husband's employment-family plan-not federal. It covered the diagnostics that found nothing wrong and covers nothing else. Tried one cycle of clomid with timed BD and one IUI on clomid, both of which failed. This is all at Columbia with Sacks, who is very nice. DH and I have decided to try and take a break for a few months since this has been very stressful and our current insurance covers nothing.

So it is open season and I am a fed employee. I am seriously considering signing up for MD IPA just for myself. The reason is my husband's open season is in the summer time and we can't afford to pay for family coverage double from now until then. However, I can afford to pay for myself and he can continue to pay the family coverage with BCBS PPO with his employer. If we are not pregnant on our own by the two year mark (next Sept), we were thinking of going to IVF and this way I can have insurance coverage. There should not be primary v. secondary insurance issues since my husband's plan covers no fertility treatments. Does this sound like a good plan to others?

Will MD IPA make us do any more IUIs? It just seems silly to waste the time and money when the sucess rate is not much higher than trying on our own for unexplained infertility. If I go this route then I think we will have to pay 50% of the IUI costs under MD IPA, but at least that is better than the 100% we paid last time. I thought about signing up for the BCBS HMO that covers IUI 100%, but then if that did not work I would have to wait ANOTHER year before open season so switch to MD IPA again.

Also, will the RE just let me go straight to IVF after 2 years TTC or will they require more IUIs also? I am also considering switching to Dominion or Shady Grove once I have insurance if we end up needing more help. Not because I had a bad experience with COlumbia, but I guess I have not had a stellar one either.

Any thoughts, ideas, suggestions regarding the situation would be great. I have been driving myself nuts trying to decide whether to sign up for MD IPA or not. Thanks and sorry if I rambled.

[Anonymous]

How old are you? That, to me, would be another primary consideration in how long you should wait. Did you have any problems conceiving #1?

I've never had MDIPA, but I can almost bet they'll make you do more IUI's before approving IVF. Will be curious to hear what others' experiences have been with this.

For what it's worth, I had the Carefirst HMO that covers IUIs at 100% and was very happy with it--never had a problem getting coverage and we paid next to nothing for a lot of infertility intervention (short of IVF, of course).

[Anonymous]

Thanks PP, OP here. I am 33 and conceived DS one the first month we really "tried". DS is 3 now, so I guess I got pregnant about 4 years ago now at 29.

I am just stressed because when we make the decision to move forward again I want to be able to do so immediately. I have to decide by next Monday, which insurance to sign up for if I am going to do it. Maybe I should do the HMO for IUIs?? This is my problem, I am not sure what is best! Thanks again

[Anonymous]

The main issue with MDIPA is that you have to have been trying for two years. Age does not matter. The two year threshold is all they care about unless you have severe endo or mf issues.

FWIW, I absolutely hate MDIPA. I just switched back to BCBS. I cannot wait for January. I don't like the HMO structure at all. If you have a good PCP who is responsive for referrals, it might not be so bad.

[Anonymous]

OP here to the PP do they make you complete a certain number of IUIs first with MD IPA? I will have been TTC 2 years in Sept so that threshold will have been met. I am just worried about them saying I have to do more IUIs first. I do have a pretty good PCP so hopefully that will be ok. Thanks for your opinion on the HMO structure though. Your experience is also why we are not going to swtich the whole family's plan over. So when IVF, if I need it is done, we still have our BCBS PPO. Thanks!

[Anonymous]

Anonymous wrote:The main issue with MDIPA is that you have to have been trying for two years.

You can lie about this. Tell the doctor it's been 2 years. They have no way of verifying.

[Anonymous]

OP here lol PP. Prob is my current RE has that it has just been over one year. I guess I could go to another RE though since I was considering that anyways-but that would not work either since they would want my records so I don't have to go through the diagnostic testing again and it is documented how long I have been TTC.

[Anonymous]

Anonymous wrote:OP here lol PP. Prob is my current RE has that it has just been over one year. I guess I could go to another RE though since I was considering that anyways-but that would not work either since they would want my records so I don't have to go through the diagnostic testing again and it is documented how long I have been TTC.

Request a copy of your medical records from the original RE and hand carry them to your new doctor. Just pull out the form with your TTC history and don't give it to the new RE. The new doctor will require you to fill out a new history form anyway. Fill this in with your revised date. I know sooo many women who have done this to get coverage.

[Anonymous]

OP -- I had this same question and I haven't gotten a clear answer on it. My question is how do they get the info on how long you've been trying? I would guess it is based on your statement or your doctor's statement. I wouldn't think they'd read through your medical records to see doctor's notes. If anyone has info please offer it up.

[Anonymous]

This thread is of great interest to me as I am in same boat as OP (TTC #2, DS is 2.5 yo). We were planning on switching from Federal Blue Cross PPO to MDIPA for IVF help, but now I am worried about this '2 year' business.
I assumed that wouldn't really be an issue since DS is over 2 years old, and as 13:15 above said, they really have no way of verifying how long a couple has been TTC. For us, it's been about 1.5 years (going first to OBGYN for Clomid, then to SG for timed intercourse, 1 failed round of IUI, and now we're paying out of pocket for IVF).
Does anyone out there know who MDIPA asks this information of? Your PCP, your RE, or your OBGYN or other?
Thanks so much for everyone's input as we navigate insurance hell!

[Anonymous]

OP, I have the same issue. I currently have BXBS Basic. DH and I have been TTC for 18 months and I am 35 y/o. Went to SG and began drugs (clomid, gonal-f and avidrul) w/timed intercourse b/c that is all that insurance will cover. I actually have a call into my RE to see what he suggests based on my age/hormone levels. If he thinks he would try 2 IUIs and then move to IVF, I am going to go for MD IPA. If he thinks he would like to try 6 IUIs, I would switch to BXBS HMO. I am pretty sure that MD IPA will not make you have 6 IUIs if you RE says that he/she does not beleive they will be successful, but you may have to go thru 2 more. Maybe you should check with your RE to see what his/her thoughts are on what your next steps would be? If you do decide to switch to MD IPA, you should try to refill your meds by the end of this year, in case you have to do IUI again. MDIPA only covers Clomid for IUIs.

If anyone could recommend a really good PCP in MD IPA, I would really appreciate it. Could be in DC or N. VA. Want to get my referral ASAP after the new year.

Thanks!

[Anonymous]

Here is another question I had for MDIPA -- you can self refer to an ob/gyn under the plan but not a specialist. So can your ob/gyn refer you to an RE? Does it have to be a PCP?

[Anonymous]

I just checked the MDIPA verbage (for 2011). I am not seeing any reference to a specific number of IUI attempts before they pay for IVF. Am I missing something? Here is what I've found:

Artificial insemination is limited to (6) cycles per lifetime.
• In-vitro fertilization is covered for married members when the following criteria is met:
- your oocytes are fertilized with your spouse’s sperm
- you and your spouse have a history of infertility of at least 2 years, or
- your infertility is associated with endometriosis, or exposure in-utero to diethylstilbestrol (DES), or blockage of, or surgical removal of one or both fallopian tubes (not due to voluntary sterilization), or abnormal male factors, including oligospermia, contributing to the infertility
- you have been unable to attain a successful pregnancy through a less costly treatment that is covered by the Plan
In-vitro fertilization is limited to three (3) in-vitro attempts per live birth and a maximum lifetime benefit of $100,000, except drugs (an attempt is counted toward this limit when injectable medications are started).
Note: We cover injectable and oral fertility drugs for covered in-vitro fertilization services. We cover Clomid (clomiphene) for other infertility services. When covered, all

[Anonymous]

OP here. Agreed PP-I saw the same thing which made me think you could go straight to IVF, but I was just wondering if I was missing something or maybe they defer to your RE? I emailed my RE and asked him when he thought he would be comfortable moving to IVF and if he would ask me to complete more IUI cycles. I will see what he says. That leads to the next questions is can you just tell your RE you want to just go to IVF and will they just do what you say?

[Anonymous]

The issue is really with the last bullet - unable to achieve pregnancy using less expensive methods covered by insurance. I spoke to the finance person at SG about that language. She said she wasn't familar with MD IPA's requirements, but she does know that Aetna usually requires 3 IUIs before moving on to IVF. I think if you had a specific issue that could only be solved by IVF or if for some reason your doctor could justify moving to IVF then the insurance will cover it. If not, then I think you would have to try least expenisve measures first. Each of these insurances have "fertility teams" that evaluate your medical history/doctor recommendations, etc and will decide what they will cover.