Approximately 7 million couples in the US struggle with infertility. Receiving such a diagnosis can be quite distressing, yet this is only part of the picture. Once diagnosed with infertility, testing, procedures like IVF or IUI, repeated monitoring visits, learning how to inject oneself, and exorbitant costs begin to add up, creating a challenging new normal. Thankfully, as of November 2019, 17 States offer some degree of fertility coverage and hundreds of companies are adding fertility benefits to their employee healthcare coverage.
However, what about the cost fertility medications?
Depending on the protocol, medications average about $5,000 per IVF cycle, however, it takes an average of 2.4 to 2.7 IVFs to get pregnant, which brings the total to an average of $15,000 plus the cost of diagnostics and treatments. While these medications are about one-fifth of the total cost of IVF, they are still expensive.
What can one do to optimize spend on medications?
1. Know your fertility coverage
Insurance companies each have their own policy for coverage. Unfortunately, this is not terribly easy to look up, so you should do your homework in advance. There are two questions you need to ask.
“Do my fertility medications count toward my lifetime fertility benefits?”
For example, let’s say you have a $25,000 cap for fertility benefits. Some insurance companies count procedures and medications toward this total while others don’t.
“How much is counted toward my $25,000 limit?”
When a pharmacy bills the insurance company, they are often charged full rates. Thus, it may be better to self-pay and then submit for reimbursement. Why? Because when you, rather than the pharmacy, submit the prescription claim to your insurance company, the dollar amount applied toward your total fertility benefits cap may be less.
2. Research your medication coverage
You can look up medication costs via your insurance company’s website to estimate what your total out-of-pocket expenses will be. Navigate to the pharmacy section, which will link you to your pharmacy benefit manager (PBM) (e.g., Express Scripts). There will be a section typically called “Estimate your Medication Costs.” Type in the medication name and dose.
Once you submit this information, it will provide you the estimated costs. Important to note is the fine print. Some medications are covered under certain circumstances only. Thus, be sure to read the pricing information carefully.
If you see the alert about a given medication being covered under certain circumstances only, try contacting your insurance company for more information. However, be aware that the response tends to be, “We won’t know until the prescription is submitted and your doctor provides documentation.” If this is the case, assume worst case scenario, in that you will pay full price.
3. Look into a Pharmacy Benefit Manager Coupon (e.g., GoodRx)
A popular Pharmacy Benefit Manager coupon is GoodRx. It is a free app providing the cost of a given medication at all the pharmacies in your local area. Once you download the app, you type in your medication and zip code, and you will see a list of pharmacies and their respective pricing. Additionally, the app will provide the distance of each pharmacy from your location along with its address and phone number.
Once you pick the pharmacy, save the coupon and present it at the pharmacy (or call the pharmacy in advance and provide the discount code over the phone). If you do the latter, take a screen shot of the coupon just in case the pharmacy asks for it.
Important to note is that the GoodRx coupon does not work with your insurance, but instead, it is used in place of your insurance. According to the GoodRx blog, “Paying with a GoodRx coupon is considered an “out-of-network” purchase, and it’s up to the insurance company to decide if they’ll pay you back—or whether they’ll count it towards your deductible.” They spoke with several insurance companies to get a straight answer to this question but were unable to.
If you use the GoodRx coupon and your insurance does not cover the medication, then the medication cost won’t count toward your maximum fertility benefit.
4. Research whether your medication comes with a Manufacturer Coupon
Pharmaceutical companies (i.e., the drug manufacturer) issue coupons that could bring the cost of your medication to $0. These coupons only work if you use the branded product and come with several caveats, so be sure to read the fine print.
Important to know is you cannot apply the coupon to previous purchases, so do your research in advance and then submit your prescriptions. Typically, you submit your information and receive a “card,” which you provide your pharmacy. Each time the prescription is filled, the pharmacy uses the card until you meet the maximum dollar amount for the year.
This is separate from PBM coupons (see above) and processed via your insurance carrier.
5. Order just what you need
Ideally, prior to your cycle, you and your Reproductive Endocrinologist agree to your protocol, which includes a list of medications and estimated dosing. Given the REI cannot predict what will happen between your Day 2 or 3 bloodwork and egg retrieval, the nurses will order based on their best estimated guess. Sometimes, however, a clinic may be overzealous and order much more than required. If you have insurance coverage and are just paying a co-pay, this may not be an issue, and frankly, take advantage of having extra medications on hand! However, if you are cash paying, this could swing your out-of-pocket expense by hundreds, if not thousands, of dollars.
6. Apply for a loan
Organizations like EggFund provide fertility-related expense loans. You can look for a full list of organizations that provide loans on Resolve’s website (and see the list of resources below). A few tips:
Check the credit score requirement: Loans tend to have a policy for what your credit score must be in order to quality.
Check what the loan covers: Each company has its own rules for what the loan is for (e.g., treatment, medication, adoption) and the maximum dollar amount you can take out. Read their requirements to best determine which organization meets your needs.
7. Determine if you qualify for a Patient Assistance Program
Pharmaceutical companies have what is called a “Patient Assistance Program” (PAP). According to RxAssist, the PAPs are “created by drug companies to offer free or low-cost drugs to individuals who are unable to pay for their medication. These Programs may also be called indigent drug programs, charitable drug programs or medication assistance programs. Most of the best known and most prescribed drugs can be found in these programs.”
You can look up whether you qualify via the pharmaceutical manufacturer of your fertility medication or via RxAssist’s website.