Fertility treatment coverage & lifetime max questions

Hello!

My age is 33, family income about $100,000) Ohio health insurance Medical Mutual states it covers “up to $12,000 per covered person” as the “maximum lifetime benefit per covered person” for infertility.

  1. Does that mean since my husband and I are both covered on the plan, that we really can have $24,000 covered total? Or does that only cover the woman actually having the procedures done?
  2. I am not sure what “maximum lifetime benefit per covered person” means–if we spend more money than that on fertility treatment, does that mean that additional spending does not even count towards our deductible? Does that mean no percentage of the fertility treatment is covered past that amount?
  3. Occasionally the employer switches the healthcare plan to another one (Anthem, UHC, etc.). If they do this for the next year, would we likely get additional fertility coverage even though we met the “lifetime max” on Medical Mutual’s plan? My husband and I are both employed so maybe we can just switch to each other’s insurances during open enrollment as able to obtain max coverage possible?
  4. Unfortunately our plan states no coverage for infertility prescription drugs. I guess I can check each individual med with GoodRx? Or should I call around to each pharmacy to find the cheapest ones? Any ideas are welcome.

Thank you so much for any advice, this is all so overwhelming to begin with and trying to figure out how to afford the next steps

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The treatment costs $12k for the person receiving it. They won’t bill any services under your husband’s name. Double-check with your plan to ensure it covers males as well as females.

Anything over $12k won’t be covered and won’t count towards your deductible or out-of-pocket maximum.

Lifetime maximums usually transfer between plans, but you should confirm this with the new carrier.

Be sure to shop around for the drugs. They are specialty medications, so they may be expensive and not available at every pharmacy. Check GoodRx and compare prices at different pharmacies. Walgreens often has the highest prices.

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My husband and I are currently going through IVF. Since we both carry a genetic mutation, the clinic agreed to bill some costs to his insurance, which will count towards his lifetime max, as they are testing half of his embryos. Otherwise, I handle all costs, which go towards my insurance.

I have a $5,000 lifetime max on my primary insurance and a $12,000 lifetime max on my secondary insurance. There’s no separate coverage for medications, so I pay for them out of pocket. IVF Reddit groups have helpful tips and information, and I’m happy to answer any questions you might have.

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To address point 4: GoodRx isn’t always the best option. Some fertility pharmacies work directly with manufacturers to offer cash pay discounts. Do you have a list of your medications? Does your clinic have a preferred pharmacy? Check out fertility pharmacies here and call them for pricing: Fertility Savings.

Another tip is not to order everything at once. Your cycle might last 7 days or more, so it’s hard to predict how much medication you’ll need. Check the shipping policies of your pharmacy to know when to order if needed.

Your fertility-related medications (like estrogen patches, steroids, antibiotics) should be covered under your normal plan. Insurance usually doesn’t question the purpose of these prescriptions before dispensing them.

While some people in IVF groups sell or give away extra medications, this might not be advisable.

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It’s $13K to the person with the uterus

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Unless it is related to male infertility which is not uncommon or for both for whatever reason.