NJ folks: fertility coverage with Horizon BC/BS?

kikibird · August 2010

Anyone from NJ on the board who has Horizon Blue Cross Blue Shield (HSA HMO access in particular)? DH's company is changing insurance to Horizon and we're trying to figure out what fertility coverage they have. It says on the "benefit highlights" that they require pre-approval for infertility coverage, but will cover 100% after deductible and copay. BUT, "Certain fertility services are excluded," and nowhere in the document does it list what these certain excluded services are (and apparently there isn't a plan book). Gah! I am so confused.

Just thought I might ask to see if anyone was familiar with how Horizon in NJ operates (while I wait for DH to find out more). I know I'm in a mandated state, but neither my or DH's company has 50 or more employees, so I'm not sure we qualify.

TIA!

praying*4one · August 2010

I'm not sure about the last line because my co. is over 50. We have bc/bs and are covered 100% for 3 retrievals and as many FET as needed.

Check it out because they are all different. good luck..I agree very confusing.

kikibird · August 2010

Thanks, hopefully DH will have some further insights when we get home. I just know that my current coverage, Oxford Liberty, doesn't cover very much at all. So if Horizon is as good as it sounds, I'll definitely want to switch. Of course HR gave DH barely any notice of the switch so we are scrambling to inform ourselves and make the decision!

Strunella · August 2010

I have BC/BS but I got the screw because my company is based in Missouri and the NJ mandate didn't apply. I got diagnostic coverage, but no coverage for actual treatments. He should confirm with his company's HR...you might be out of luck with the less than 50 employees rule.

Strunella · August 2010

I forgot to add that I have a PPO, not an HMO, which allowed me a lot more flexibility in seeking treatment. No referrals required.

kikibird · August 2010

Thanks Strunella, I think DH's company is NJ based, but I'll be sure to check!

AlmostLoCo · August 2010

Kiki, I think it depends on what coverage is provided by the individual employer. My company offers a bunch of insurance plans from different companies (including Horizon, I think) and all of them provide the same fertility coverage - they cover fertility treatments up to a max of $25,000, excluding drugs which are covered separately. I would suggest having your DH call his benefits representative to find out. But I'm hoping you won't even need the coverage in the first place!

kikibird · August 2010

Thanks Lori! Yeah, I guess I am just trying to make sure we have the bases covered, should we need it (though of course I'm hoping we don't --- I go for CD3 testing tomorrow so we'll see). DH is going to speak with HR today to see if we can get this question answered. He was trying to get details without having to ask specifically about fertility coverage, but his questions only got the vaguest of answers. So I told him to bite the bullet and ask direct questions of the HR rep... should be able to do so in confidence.

kinsalebride · August 2010

I would absolutely recommend going with the PPO and not the HMO. you'll get more fertility coverage that way and won't have to constantly call for approvals and stuff. when we were starting our journey we had an HMO at DH's co. and it stunk. i had to call just for my first meeting with the RE. thankfully DH was in the midst of switching jobs and when we got switched to Blue Cross/Blue Shield we did the PPO. Our coverage was unlimited IUIs and up to 3 IVFs. Meds were also covered fairly well, paid a minimal amount out of pocket. We live in NJ but both work in NY and DH's co. was well over 50 people at the time, so not sure if any of those are factors. Also, defitely call a benefits rep and have them walk through the coverage with you. they should have specific reps that deal with fertility. i know they did when we were using them. good luck.

kikibird · August 2010

Thanks, kinsalebride. DH's plan is, I believe, only a quasi-HMO, in that referrals aren't necessary. I'd love to get the PPO version but it would be double the cost of the other plan. Maybe if things get tougher for us then we'll bump it up next year (I know it would be heaps cheaper to pay for more insurance than to pay OOP for fertility treatments if we end up needing them). Just having a devil of a time getting straight answers out of anyone so far (part of this due, I'm sure, because I'm back-seat-driving this investigation -- though even DH is getting frustrated with the lack of answers now).

I think we're probably going to switch me to his plan anyway since it's better than mine, fertility coverage notwithstanding. But I kinda want to know what I'm getting into first, know what I mean?

kinsalebride · August 2010

i hear ya. we decided to go straight to the PPO from the HMO prior to our first meeting with the RE I wound up working with (initially i met w/ an RE close to our house but realized that wouldn't work since I'd have so many visits). I think it was an easy decision for us at the time because we'd been trying for over a year and had had 2 mcs by that point so we just really wanted to get and stay pg. I'm glad we went straight to the PPO though prior to knowing what we'd be in store for because we did wind up doing 3 IUIs and 2 IVFs all in, so the PPO coverage was well used.

&& · August 2010

I have Horizon BC/BS HMO and love it. I do need referrals, but I only had to make one phone call to my primary care physician for the referral to the specialist and they took care of the rest. I do not have any copays for office visits (this is KEY because there are sooooo many visits) and my meds copay is $20. IUIs, ultrasounds, bloodwork etc is all covererd 100%. There is a lifetime maximum of 3 ER's but IVFs are covered 100%. There is no maximum $$ amount and no deductible.

Check into the specific coverage they are offering. Horizon has a few different plans. We chose this one because we knew we were having fertility treatments and this was the most comprehensive. (my employer has over 50 employees)

Hope this helps- good luck!

kikibird · August 2010

&& ~ that's awesome that you have so much coverage with the Horizon HMO. I hope ours is as good (still waiting to get contact info for the rep - ugh this is a slow process)! It's so hard to know what to do when you don't quite know what you're up against. My DH (king of spreadsheets) started listing out the employees at his job last night and came up with at least 50, so maybe we'll be in luck there.

Hopefully we won't need the coverage, but I'll feel a little more at ease knowing the option is there. OOP isn't going to be an option for us (unless we win the lottery or something).

Thanks to everyone for your thoughts!

kikibird · August 2010

:sigh:

Finally got our answer. The plan at DH's company is for small businesses, so neither the HMO nor the PPO has fertility coverage. They'll cover diagnostic testing, but that's it.

BUT, further investigation into my own plan (also a small group plan) shows that I do have coverage for artificial insemination (IUI and ICI), including meds (and diagnostic testing).

So, I'm not going to switch... whew, 'cos I almost did!

mariash14 · August 2013

I know it's now 2013 but I'm suppose to be having IVF very soon, have horizon direct access bc/bs ppo and believe the coverage you spoke of is the same as mine. I'm waiting on one last pre-authorization for one of the prescriptions needed, it's 4G out of pocket and I'm wondering when you say you had to pay a minimal amount, what the amount was? I'm going crazy bc I'm suppose to be starting IVF this Tuesday, its the wedkend so im stuck waiting until Monday and we do not just have an extra 4 grand laying around. Any help you could provide would be very well appreciated!

BLISS KISS · August 2013

I have NJ DIRECT TOO. THEY PAY 100%. MY MEDS WERE$100.00 . MY ET IS TOMORROW. BEST WISHES. .

BLISS KISS · August 2013

They paid for my cycle in 2010 too. It was NJ PLUS THEN. STATE EMPLOYEES.

BLISS KISS · August 2013

You'll be ok. Rest assured. ..

StephPV · August 2013

This type of coverage is determined by the employer not the insurance company or plan.

BLISS KISS · August 2013

Let me know how you make out. NJ Direct is for State covered employees I believe. So , keep me posted!!!

HeathernSteven · August 2013

I do! in NJ small businesses do not have to provide IVF but they need to provide some type of IUI coverage. So I had at least 3 IUI's and one of them being an injectible one, meds only cost me a $90, which was nice because I I do have copays and co insurance. Best of luck! use Hubby as a 2ndary insurance so perhaps you get more coverage....best of luck!

NJ folks: fertility coverage with Horizon BC/BS?

Re: NJ folks: fertility coverage with Horizon BC/BS?

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