Best FEHB for monitoring, drugs, IUI?
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Anonymous
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My husband and I recently moved cross-country for my federal job. I was diagnosed with PCOS / anovulation last year and went through all the tests and a couple trial cycles to find the right dosage. Since my egg supply looks good, what I'd like to do is continue on this path for a few more cycles and see how it goes. While IVF may be in our future, for now I am just looking at the lower-level services (drugs, monitoring, possibly IUI).
Does anyone have advice on whether and which of the FEHB plans would help cut down on costs for these? For example I understand Kaiser will pay 50% of drugs/monitoring/IUI (for now), but I've read elsewhere on this forum that the providers inflate the costs when you use insurance, and might charge less overall when you're paying OOP. Does what you pay just end up being roughly the same? Is there any deal here or am I wasting my time trying to figure it out? 
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Anonymous
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Great question. Right, supposedly Kaiser still covers 50% of IUI/meds. I was on it when it still covered 50% of IVF, and it was a great deal because the OOP max is pretty low before everything gets covered 100%. I think it was only $2250 then. So after paying $2250, EVERYTHING was covered 100%. If the OOP max is still low like that, and you think you'll try IUI a couple of times in a year (or if you think you'll try injectables even once), then it's still a really good deal. The one downside is that you are restricted to the Kaiser network, so you have to find a Kaiser obgyn, and then if you want actual fertility help, you have to get the referral to an RE. Shady Grove Fertility is the only approved provider for REs. Shady Grove meets some people's needs and not others'.
I am currently on BCBS Basic. I was on it while I was doing IVF, but before Kaiser, and all monitoring is covered for a $40 copay. Some meds that you may need (Clomid/Letrozole, progesterone, estrogen, trigger shot) are covered when you are doing timed intercourse, but not when you move to IUI. A few meds are cheap even when they're not covered, like Letrozole, Clomid, and Estrace, so that's not a huge savings. But it's great to get monitoring covered at least. There is a federal CareFirst plan that used to cover IUI, but I'm not sure that it does this year. Aetna has a small benefit for people doing IVF, in that Shady Grove will honor the Aetna member price for an FET, but there's otherwise not much benefit beyond that. If you will be living in Maryland, it's a state that is mandated to cover IVF. Since you have a new job and changing insurance, you have a qualifying life event and could sign up for a CareFirst plan on the MD exchange. It's VERY expensive this year, but if you thought you might do more than one cycle of IVF, it can still be a good investment, but perhaps not better than a shared risk program at any of the local clinics if you meet the age requirement. |
Anonymous
| To clarify what the PP said, Aetna covers roughly half of services at Shady Grove because of their negotiated rate — but it’s more than just FET. It’s also a big break on price for IUIs and IVF (at least it was....). |
Anonymous
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^ this is all EXTREMELY helpful information - thank you so much for taking the time. They make this impossible to figure out.
I did not catch the $40 copay for monitoring with BCBS Basic. That's actually pretty huge. It sounds like it really might be worth doing that or Kaiser for the phase I'm at right now. FWIW it looks like Kaiser OOP max is now $3500 for standard / $4000 for basic. Are injectables really that much here, that you think it would add up that quickly? Back west I thought trigger shots ran $100-200 a pop. Maybe that was the reduced rate. My hope is that I can get a couple cycles in by November / open season, so then I'll have a better idea if we'll be doing IVF and can reevaluate the options. (Unfortunately we don't live in MD but thanks for the tip!) |
Anonymous
Do you know/remember if that includes monitoring? |
Anonymous
By injectables I don't mean just a trigger. Sometimes when people do IUI or even timed intercourse, you might inject gonadotropins (the same injectables used in IVF) to get multiple follicles. How much you need to get just a few depends on your ovarian reserve. If you are DOR, you could require higher doses than if you have good reserve. These drugs can run in the thousands. If it would be helpful, maybe tomorrow I can look back over my pharmacy records see what Kaiser charged for one Gonal F pen, for example. Then you can also call and get an OOP price at a pharmacy like Freedom or SMP or something like that for comparison. If you've never tried Clomid or Femara/Letrozole, injectables would likely not be your first step, but it might be something you try a few cycles in. Also, if you are PCOS, you might be a high responder and would require less meds than the average person. |
Anonymous
The way I remember it, monitoring was included in the package rate that was discounted, so yes. My retrieval and all monitoring was roughly $6000 instead of $12 or $15k (or whatever it costs OOP) and my FET (monitoring, ultrasounds, transfer, pregnancy ultrasounds) were about $1800 instead of $4600. Meds not included in anything, of course. |
Anonymous
Thanks for both of the above clarifications! re:
Ah - obviously I'm still relatively new to this. So far low dose letrozole has done the trick for me, w multiple follicles developing, but I understand that can change. Thanks! |
Anonymous
| I have BCBS Carefirst Standard through my husband’s job. I just switched a few months ago because I had a successful IUI last year with different insurance that no longer covers anything. Folks on this forum informed me that the local (DC, MD, VA) BCBS Carefirst covers up to 6 IUIs. The coverage info from BCBS says it covers 6 at 50 which is better than nothing. . Columbia Fertility said it covered nothing but gave me an estimated cost of $500-something including monitoring but not meds. For my successful IUI I used Clomid and an Ovidrel trigger which was $110 back then. If IUIs don’t work then we are one and done. Good luck! |
Anonymous
| NP: Just to clarify are you a federal employee? because if you are under Kaiser plan most infertility treatment including IUIs, monitoring & meds will be covered at 50%. the unfortunate piece is should IUI not work for you none of the fed health plans cover IVF. just an FYI. Hope IUI works for you and you don't have to worry abt IVF. Good luck |
Anonymous
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OP here, since it is open season and maybe other feds are figuring this out now for IUI.
I went with Kaiser Basic and the only downside I experienced was the wait time to get started -- I had to get referred by Kaiser, then wait a month for a new patient appt at SGF, then approved by Kaiser, then genetic screening, then finally start. Probably 4-5 months total from selecting insurance to starting my first treatment cycle. In retrospect I would have scheduled my SGF appointment ASAP (before the referral, or even before selecting insurance, if that's possible). But the 50% coinsurance has been essential as it reduced the cost of genetic screening by a couple hundred, and seriously reduced the cost of injectables, as a PP mentioned -- it came to $650 WITH insurance for one cycle of gonal-F (would've been $1300) so it's been worth the extra hoops to jump through IMO. Also I like that the Kaiser capitol hill pharmacy is open 24/7. One more thing: I'm not sure yet if there is a limit on IUIs Kaiser will cover per year (or ever?) -- in brochure it says based on "dr. recommendation." TBD Still -- I think Kaiser is probably the best deal out there for my current course of treatment. Good luck! |
Anonymous
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For any other feds who are looking for IUI coverage but don't want Kaiser: The federal Carefirst BlueChoice HMO option will also continue to cover up to 6 IUIs in 2019.
I've had the Standard Self plan (DH is also a fed and carries his own plan b/c it's been cheaper for us up till this open season now that we're expecting) this year for the IUI coverage and found the plan to have excellent coverage overall. It does cover drugs for TI and IUI with pre-authorization. After a bad experience in Jan. '18 at GW IVF after having been a patient there for about 5 months, I did consults at Dominion and Columbia to decide where to go next. We went with Dominion which is, unfortunately, out of network for the CareFirst HMO plan. However, while I had to pay the out-of-network deductible, Dominion only held me accountable for the "allowed amount" charges defined by my insurance, and every cent I paid out-of-network was still credited toward the max out-of-pocked for both In- and Out-of-Network...the In Network max out-of-pocket is $2500 for the Self plan ($5000 for the self+1 and self+family options) and it's staying that way in 2019. Between paying the out-of-network costs at Dominion, prescription co-pays, and specialist co-pays earlier in the year (I see an endocrinologist every 1-2 months), I hit my In-Network out-of-pocket max by July or August and haven't paid a cent for anything since then. I would have paid far less if I'd done my IUI at an in-network provider, but this plan was well worth the money even with my decision to go out-of-network due to the other level of coverage it gave and the whole fact that once I'd paid $2500, I didn't have any more costs for in-network services (including pharmacy) for the rest of my plan year. The biggest drawback I see to it in 2019 is that the premium is going up by quite a bit compared to this year. However, if I were still in need of IUI, I wouldn't hesitate to keep it for another year. (We're expecting in March and, after very detailed cost analysis, have decided to go to BCBS FEP Basic for Self+Family.) |
Anonymous
Hi OP! I have Kaiser Basic and love it! We're on our 3rd IUI--the authorization letter originally only authorized 3. I'm curious if other federal Kaiser folks were able to get more than 3 IUIs authorized in a calendar year? We've almost hit our OOP. Oof! |
Anonymous
Also, curious about this! |