Kaiser - Infertility Services DO count toward OOP Max

[Anonymous]

Since replies are often not provided, I wanted to provide a follow-up. I'm the original OP. I'm happy to report that after paying $2500 for my meds, I've had to pay ZERO for additional meds through Kaiser or for ANY of my treatment for SG.

I just made sure to go to Members Services and asked them to note that I had reached my catastrophic out-of-pocket. Then, when returning to their pharmacy for additional meds, I've reminded them each time that I had reached my OOP max. It's worked like a charm.

Our first IVF cycle (and hoping we don't need any additional) has only costed us a total of $2500 through Kaiser and SG.

Figured this would be good news for folks trying to make a decision between Kaiser and Aetna in the future.

[Anonymous]

I am a NP and I can also say that after the first $2500 of meds I have paid zero for everything after that with Kaiser. It has saved me probably close to $8,000.

We did two retrievals with SG. On the first one, I gave them a deposit toward the cost, and the second seems to have been free because I had such a large credit from the $ Kaiser paid back. We also did ICSI and PGS so I did have to cover that OOP on the first round but have paid $0 so far on the second.

[Anonymous]

Anonymous wrote:Since replies are often not provided, I wanted to provide a follow-up. I'm the original OP. I'm happy to report that after paying $2500 for my meds, I've had to pay ZERO for additional meds through Kaiser or for ANY of my treatment for SG.

I just made sure to go to Members Services and asked them to note that I had reached my catastrophic out-of-pocket. Then, when returning to their pharmacy for additional meds, I've reminded them each time that I had reached my OOP max. It's worked like a charm.

Our first IVF cycle (and hoping we don't need any additional) has only costed us a total of $2500 through Kaiser and SG.

Figured this would be good news for folks trying to make a decision between Kaiser and Aetna in the future.

What did you have to show member services that you have reached $2,500? I easily reached that last year but when I received my statements, it didn't show that I have reached.

[Anonymous]

Anonymous wrote:I am a NP and I can also say that after the first $2500 of meds I have paid zero for everything after that with Kaiser. It has saved me probably close to $8,000.

We did two retrievals with SG. On the first one, I gave them a deposit toward the cost, and the second seems to have been free because I had such a large credit from the $ Kaiser paid back. We also did ICSI and PGS so I did have to cover that OOP on the first round but have paid $0 so far on the second.

Why do you only mention meds? Is the 2,500 oop max for only meds or for everything?? As someone only needing to do transfers the med costs don't bother me as much.

[Anonymous]

Anonymous wrote:

Anonymous wrote:Since replies are often not provided, I wanted to provide a follow-up. I'm the original OP. I'm happy to report that after paying $2500 for my meds, I've had to pay ZERO for additional meds through Kaiser or for ANY of my treatment for SG.

I just made sure to go to Members Services and asked them to note that I had reached my catastrophic out-of-pocket. Then, when returning to their pharmacy for additional meds, I've reminded them each time that I had reached my OOP max. It's worked like a charm.

Our first IVF cycle (and hoping we don't need any additional) has only costed us a total of $2500 through Kaiser and SG.

Figured this would be good news for folks trying to make a decision between Kaiser and Aetna in the future.

What did you have to show member services that you have reached $2,500? I easily reached that last year but when I received my statements, it didn't show that I have reached.

I went to member services, asked them to pull up my expense reports (which I needed to submit to my FSA anyhow) and then used that to show I had reached my OOP max. My first round of meds alone reached that max and they even gave me a refund check. Hope that helps.

[Anonymous]

Anonymous wrote:

Anonymous wrote:I am a NP and I can also say that after the first $2500 of meds I have paid zero for everything after that with Kaiser. It has saved me probably close to $8,000.

We did two retrievals with SG. On the first one, I gave them a deposit toward the cost, and the second seems to have been free because I had such a large credit from the $ Kaiser paid back. We also did ICSI and PGS so I did have to cover that OOP on the first round but have paid $0 so far on the second.

Why do you only mention meds? Is the 2,500 oop max for only meds or for everything?? As someone only needing to do transfers the med costs don't bother me as much.

It's for everything, so long as it is covered. Not all of the procedures of frozen transfers are covered, so you'll probably have some out of pocket costs. You'd need to discuss this with your provider. However, even with frozen transfers, you'll likely have some medications that will be covered (i.e., progesteron and estrogen).

[Anonymous]

Does anyone know if the donor egg process would be covered by Kaiser?

[Anonymous]

Anonymous wrote:Does anyone know if the donor egg process would be covered by Kaiser?

No.
No coverage for donor egg or if you are using OE+ own sperm with gestational carrier.

[Anonymous]

Ok, that's what I thought. Thanks.

According to the Kaiser plan it says 3 attempts at live birth but also a $100K lifetime amount. What does that mean? Does that mean you are only covered for IVF 3 times for your entire life? Or does it mean 3 time per year or until you reach $100K?

[Anonymous]

Anonymous wrote:Ok, that's what I thought. Thanks.

According to the Kaiser plan it says 3 attempts at live birth but also a $100K lifetime amount. What does that mean? Does that mean you are only covered for IVF 3 times for your entire life? Or does it mean 3 time per year or until you reach $100K?

Not unique to Kaiser. This means you have 3 attempts to get a live birth before they stop covering IVF. Once you have a live birth, the clock resets and you can continue this up to a max total expended (on Kaiser's part) of $100K.

[Anonymous]

OK, so that means you have 3 tries at IVF and if you don't conceive then Kaiser won't cover it anymore.

What happens if you start out as an IVF cycle but then it's cancelled because you don't have enough follicles, so you convert to IUI. Would Kaiser count that as an IVF attempt? Or chalk it up under IUI.

[Anonymous]

Anonymous wrote:OK, so that means you have 3 tries at IVF and if you don't conceive then Kaiser won't cover it anymore.

What happens if you start out as an IVF cycle but then it's cancelled because you don't have enough follicles, so you convert to IUI. Would Kaiser count that as an IVF attempt? Or chalk it up under IUI.

You should call Kaiser and ask. I had MD IPA last year and they counted the cycle as starting with the first injection.

[Anonymous]

Thanks. That figures they would go with the most beneficial interpretation for them.

[Anonymous]

Seems like Kaiser could be the cheapest way for feds to get IVF coverage, if all you pay is the $2500 OOP max. So what if your meds don't quite add up to $2500--does any part of the monitoring or retrieval make up the difference toward meeting the max so that the remaining costs would be free? Also, are there any coverage restrictions on Kaiser? For example, Aetna has rules about FSH being below 19 and no coverage for infertility that is age-related. Does Kaiser have any similar rules/situations that could mean a person's cycle wouldn't be covered after all?

[Anonymous]

Anonymous wrote:Seems like Kaiser could be the cheapest way for feds to get IVF coverage, if all you pay is the $2500 OOP max. So what if your meds don't quite add up to $2500--does any part of the monitoring or retrieval make up the difference toward meeting the max so that the remaining costs would be free? Also, are there any coverage restrictions on Kaiser? For example, Aetna has rules about FSH being below 19 and no coverage for infertility that is age-related. Does Kaiser have any similar rules/situations that could mean a person's cycle wouldn't be covered after all?

I doubt your meds will not add up to $2500. I just did my first cycle, and just the first bit of meds (had to get more later) got me over the $2500 hump. You have to buy the meds through Kaiser's pharmacy, which is not cheap. However, if you don't reach $2500 through meds, then yes, they'd count some of your monitoring costs toward the $2500 until you reach the max.

Just a tip -- the pharmacy at Kaiser seems to forget to check if you've reached your out-of-pocket maximum. Just remember when picking up additional rounds of meds that you've reached the max. They'll adjust it and then make sure not to bill you.

In addition, once you reach the out-of-pocket max, make sure you inform SG so their financial office can verify this with Kaiser.

Good luck everyone.