MDIPA coverage for IVF meds

[Anonymous]

On 4/1/13, MDIPA apparently switched companies it used to handle its pharmaceutical coverage from Medco to Optim. I ordered meds for my first-ever IVF cycle on 3/30 and got a call from Freedom Fertility (the only pharmacy that MDIPA covers for these drugs) about a week later telling me that Optim was denying coverage for all of my meds despite having an authorization on file for an IVF cycle that included all medications. It's taken about a week, but I finally got Optim to honor the authorization and covemake r all of the meds except for one. To save everyone else the hassle, I wanted to share the result of all this madness: if you're having trouble getting coverage, try having your RE send over the prescriptions/dosages to their "Specialty Pharmacy Program" rather than the regular pharmacy program, which will deny everything. The number is 866-429-8177. It literally took everyone (Freedom Fertility, United Healthcare, and Shady Grove) to figure this out and I almost missed my cycle start date. Good luck to everyone!

[Anonymous]

THANK YOU kind OP! I am an MDIPA member, and they literally would not give me a phone number for Optim.

[Anonymous]

The switch to Optim has been an absolute disaster. I needed more meds 3/4 of the way through my IVF cycle and they had just switched to Optum that Monday and it was maddening! Somehow Freedom got me my meds but I think they went through a back door cause Optum was hopeless. The other thing that we discovered during the process was the Optum outsources to Freedom Fertility as well for all fertility specialty meds so I don't understand what the issue is!

[Anonymous]

I am just starting my first cycle with MDIPA, with the meds through Freedom, and strangely enough they paid for everything except the Ganerelix. Since I have to start stimming tomorrow I didn't have time to argue - and I will follow up next week - but it seems really strange that they won't cover what I understand to be a very basic IVF medication. However, my copay on all the other meds was only $200 which is fantastic. I was out of pocket for this last time and all my meds cost close to $4K, but I am on high dosages of follistim.

[Anonymous]

OP here. I was having the same problem with the Ganerelix (sp?) but just got word that they are now covering this as well. It seems like things are getting straightened out over there.

[Anonymous]

They cover all the meds. Your RE may not have included it in the authorization list . Just get them to resubmit that. The med coverage is indeed fantastic. We paid $270 I think for all IVF drugs for my current fresh cycle.

[jindc]

ad a similar problem (with the previous company, but it was still annoying). Freedom sent me the drugs with no cost and then backdated once the authorization went through.

They also wouldn't cover my lupron trigger so I had to pay OOP but then did cover it, and I got a refund check.

Freedom will work it out, their insurance people are amazing. They were calling me at 8 or 9 PM to help get it sorted out.

[Anonymous]

I also used Freedom Fertility and ended up paying 300 OOP.

[Anonymous]

Any recommendations on how to get MDIPA to pay for either Cetrotide or Ganirelix? I've spent 3 hours today on the phone trying to appeal, but all they say is that Optum does not have either medication listed as eligible for coverage. When asked if I could appeal, they said MDIPA would only accept appeals in the mail and it takes 15 days. I'm getting very frustrated with them.

[Anonymous]

With you and your nurse / financial people on them, they'll cover it - it's difficult to have a cycle without those meds!

It does take them a short while to go through the appeals process, but they will pay you back. My advice would be to pay for it OOP then you'll get a check back from MD IPA for your cost. That happened to me with my (Lupron) trigger - they wouldn't cover it, but I obviously needed it in a timely manner. My clinic wrote an appeal, and 2-3 weeks later, I had a check.

Good luck!

[Anonymous]

Thanks! For anyone else who has this problem, I did get a solution this morning: After spending 5 hours on the phone I contacted the following people: OptumRx - Medical Benefit Only, 888-739-5820. It's a different number than what was posted April 1st on this string. The people at this phone number explained that OptumRx Pharmacy coverage has changed the eligible medications and both Cetrotide and Ganirelix are no longer eligible through Freedom, so I expect others will experience this problem. You need to create an account with OptumRx. The help center at the 5820 number will set your account up. Then either Freedom, or your RE needs to fax or call in a copy of the prescription. The meds will be paid for through your medical plan, not your pharmacy (though I know on our 2013 brochure that it says all meds are paid through the pharmacy plan). You'll be responsible for 50% of the med costs.

[Anonymous]

Thanks for sharing this info! I just tried the 5820 number because Freedom told me that coverage for Del Estrogen (injectable) was denied. This is for a FET cycle. I called the pharmacy number on the back of my MDIPA card (888-290-5416) and they said that this medication in its injectable form was not covered by my provider. The 5820 OptumRx # said that the "billing dept" was closed, so that I needed to call back tomorrow. Ugh, I hope this becomes one of those meds that they will eventually cover as well.

[Anonymous]

@15:38 - are you sure about the 50% med coverage? That is a significant difference. Is this just for the ganirelex or for all injectible meds? This switch to Optum has truly been horrible. So can someone summarize the process because my understanding from talking to Optum Specialty Pharmacy was that all fertility meds are handled by Freedom Fertility still.

[Anonymous]

This is 21:24. I'm getting ready to start a FET cycle. My prescriptions were called into Freedom, all were covered, except for one (Del Estrogen). I called OPTUMRx at 888-739-5820 and they verified that Del Estrogen is covered by my medical benefit versus pharmacy benefits. They gave me the direct number to the OPTUMRx pharmacy 866-815-5338 and asked that my Doctor's office call in the prescription for Del Estrogen. Because I need it quickly, they told me to have the doctor's office say it needs to be escalated. I then called Freedom and asked that they ship all my meds for the FET with the exception of Del Estrogen and explained that this will be filled by OPTUMRx. They were very familiar with some prescriptions being filled through their pharmacy and others being filled through another because of this distinction between medical versus pharmacy benefits. I do not know the final cost of Del Estrogen through OPTUMRx, but I'll take some coverage over none any day. Thank you OP for doing all the leg work on this and sharing your findings!!

[Anonymous]

I posted the info on 4/19. All of my medications but Ganirelix went through Freedom with absolutely no problem. It was just the $800 worth of Ganirelix that I've had to jump through hoops on. Fortunately it looks like the 50% copay for Ganirelix is going to go through and my meds will be here Thursday. Hopefully May will be a happy month for all of us!