Reply to DC Government insurance coverage options for IVF

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[quote=Anonymous]OP here - I did not hear back from Aetna, but did get preapproved by them for IVF, so based on what they told the clinic, here's my understanding of the Aetna coverage (HMO, though I think the PPO is the same/similar):

There is no lifetime maximum, the IUIs are covered at 50% with no limit on the number and IVF coverage is capped at 3 attempts per lifetime. HOWEVER, see what counts as a cycle below AND note that "per lifetime" means any prior attempts, including any self pay or with another insurance carrier. Infertility services are covered at 50%. Comprehensive fertility services (medicated TI, IUI) do NOT count toward the annual out of pocket maximum, but IVF DOES count toward the OOP max.  All meds (injectible and non-injectible), freezing, and cryopreservation are excluded from coverage.  Things like ICSI and other testing are covered (at

What counts as a cycle?  The cycles for IUI and IVF are counted separately. A retrieval + freeze all cycle, frozen embryo transfer, and retrieval + fresh transfer all count as separate cycles.  This means that if the clinic decides to do a freeze all and frozen transfer (which my clinic does 60% of the time), then that counts as 2 of your 3 cycles.

OP again here - my take is that if you want to do multiple IUIs, the Aetna plans give you more coverage than UHC (I don't really want to switch to Kaiser, so didn't closely compare that option).  However, you'll be paying 50% of the IUI, plus meds for all cycles.  Once you switch to IVF, you'll pay the first $3,500 until you hit the OOP, then you'll be covered at 100% for the remaining cycles.  But you will still have to pay for meds ($3-5k per cycle) and storage ($1,200 per cycle and $500 once a year for storage) OOP because they are totally excluded from coerage.  Because a cycle that is a retrieval then frozen transfer counts as two cycles, it's likely you'll exhaust your 3 cycles before you'd hit UHC's $30k limit.  If you have PCOS or otherwise expect to bank a lot of embryos your first retrieval, then your math may work differently.  We'll likely need multiple retrievals, so the Aetna plan would give me fewer total cycles and each cycle would cost more.

Phew, I've been reading the contracts and putting fake scenarios into budgeting spreadsheets for weeks.  I hope this is helpful for others![/quote]

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