Insurance coding question

mm29

I’m not sure why I did not check into this with my first IVF, I guess it was because I knew that IF benefits were not covered, so I never checked into it. Anyway I called my insurance yesterday, what I learned is that all injectable medications fall in the category of “medical benefits.” They have a list of meds they just do not cover (i.e. Stims, clomid, hcg, etc); essentially the meds that are only used for fertility treatments. PIO is covered and some others are covered under medical because they can be used for other things that are not related to fertility treatments. The catch is they have to be coded for something that is not related to fertility treatments. I also have to change the pharmacy that I can use to one that is “in network” or the meds will not be covered at all. Has anyone else ever come across this? If so, do you know how your RE coded the meds? I was thinking RPL, that being said I’m guessing I do not fall in this category since I have only had two c/p. Do c/p's count as a loss?

Twinkie0612

I've always had the pharmacy run my prescriptions through insurance and they picked up things like antibiotics and folic acid. For my FET they picked up my estradiol as well. I never had to have my prescriptions coded a different way though.

mm29

@IFinTN, I think I may ask to have pio RX filled at my regular pharmacy.  I asked what pharmacies were "in network" and the listed "Walgreens specialty pharm." so I may have them attempt to send the RX there.  I hate that we have to deal with this crap on top of evertying else!! 

J&D2007

My insurance says injectibles for fertility are covered with prior authorization, but when I called they said that they weren't so I'm in limbo too. As far as coding, you could just call he insurance and try to get an answer from them on which circumstances they would be covered... They probably won't be real helpful though..

mm29

J&D2007 said:

My insurance says injectibles for fertility are covered with prior authorization, but when I called they said that they weren't so I'm in limbo too. As far as coding, you could just call he insurance and try to get an answer from them on which circumstances they would be covered... They probably won't be real helpful though..

I called them, they were not helpful, which is why I asked.  The person I spoke with indicated she didn't know the codes or what diagnosis would be approved so it sounds like a guessing game. 

scooteriste

Meds don't get coded, per se. If a doctor writes you a script and you take it to the pharmacy, the tech runs the drug code through the system to see if your insurance will pay or not. Some plans are set up to be more stringent than others and less expensive meds that are multi purpose (Vivelle, Femara, PIO, etc) will be filled by insurance without issue, so you should always try.

J&D2007 call your insurance back and ask them to look for a rider on the plan. It may be hard to find. Then, if you have coverage for infertility meds, call your RE and ask them to request pre-authorization for the meds. Once they have that, they need to fax over the prescriptions *with* the pre-auth forms to the pharmacy. Then follow up with the pharmacy and see if the meds will be covered. It's a lot of work. Don't be afraid to make friends with the insurance/finance people at your REs office, they sometimes have good insight into how to get things pushed through.