Texas ladies


#1

Ok I got some questions for the ladies in Texas regarding your insurance.

I work for local government and have excellent insurance
90/10 policy $250 deductible and $1000 max out of pocket!! Great right!

Yeah except that it has ZERO infertility…yesterday Iran across that Texas is one i
Of 13 states to mandate infertility coverage including IVF, has anybody dealt with this or know what to do. I am scared to “rock the boat” without knowing exactly what to do. I have had 6 :bfn: and would like to move to ivf but its not even a possibility for financial reasons…lookin for some help…


#2

From what I understand, mandated doesn’t necessarily mean they have to. I’m in tax and we are paying it all out of pocket. We saved for a yr on the down payment, which was half and are making monthly payments on the rest.


#3

I believe the “mandate” only states that the insurance company must offer it to employers but the employer does not have to include it in the policy and most do not as it drives up costs.


#4

I answered this on another post of yours… but i’ll put it here also…

Texas Infertility Insurance Mandate

Texas Infertility Insurance Mandate Limitations
There are certain criteria that must be met in order for a Texas insurance plan to be required to offer coverage for IVF costs. According to Texas fertility treatment insurance law, the following conditions must be met in order for IVF costs coverage to be offered:

The IVF patient must be an individual covered under the group health benefit plan
The eggs for the IVF procedure must be fertilized only by sperm from the patient’s spouse
The IVF patient and her spouse must have a history of infertility of at least five continuous years of duration, unless the infertility is associated with any of the following conditions: endometriosis, in utero exposure to Diethylstilbestrol (DES), blockage or surgical removal of one or both of the fallopian tubes, or oligospermia (low sperm count)
The IVF patient has been unable to achieve a successful pregnancy through other less costly fertility treatments offered under the health plan
The IVF procedures are performed at a fertility clinic or medical center that conform to the IVF guidelines set in place by the American Society for Reproductive Medicine (ASRM)
Religious organizations who believe that IVF goes against their beliefs and practices are not required to provide coverage for IVF costs.

Insurance Coverage for Infertility Laws

Tex. Insurance Code Ann. § 1366.001 et seq. (1987, 2003) requires that all health insurers offer and make available coverage for services and benefits for expenses incurred or prepaid for outpatient expenses that may arise from in vitro fertilization procedures. In order to qualify for in vitro fertilization services, the couple must have a history of infertility for at least five years or have specified medical conditions resulting in infertility. The law includes exemptions for religious employers.


#5

It must just be offered to your employer, but your employer may have declined the coverage. Even if it is offered, there are so many loopholes to jump through, for me, even though I am really infertile, I did not qualify (when my employer had this).

If you have BCBS of Texas (I think it must be “of Texas”) then you can call the speciality pharmacy (Triessent) and they will file the meds under your major medical and they will be covered. This saved me tons of money. I thought it was a mistake, I even called BCBS and they said my meds weren’t covered b/c they were specifically excluded under my policy. Then, I called BCBS and someone else told me they were. However, Triessent handles all of this for you and you don’t even have to worry about it. They took care of everything once I found out about them (I paid for a few cycles of meds before I figured this out). You may not have BCBS of Texas, but just in case anyone does and reads this, I would like to pass this on…

Also, if none of this works for you, I did not have the money to pay for my cycles, I ended up getting a loan through the bank at a low interest rate. I also initially got a medical loan through I think Capital One or something like that. I figured I only have a certain amount of time to have children, but all the time in the world to pay the money back. I was able to pay off the two cycles it took to have my daughter right before she was born (I put absolutely all my money towards this until I had her).


#6

I’m in Texas and the only thing covered by my insurance was my Clomid and progesterone. The IUI procedure was not covered, nor was my trigger shot. If I did IVF, that would not have been covered either. I even had to pay for most of my blood work and fertility testing. It’s all in what your employer has chosen to include in their insurance offerings!


#7

[QUOTE=houston]It must just be offered to your employer, but your employer may have declined the coverage. Even if it is offered, there are so many loopholes to jump through, for me, even though I am really infertile, I did not qualify (when my employer had this).

If you have BCBS of Texas (I think it must be “of Texas”) then you can call the speciality pharmacy (Triessent) and they will file the meds under your major medical and they will be covered. This saved me tons of money. I thought it was a mistake, I even called BCBS and they said my meds weren’t covered b/c they were specifically excluded under my policy. Then, I called BCBS and someone else told me they were. However, Triessent handles all of this for you and you don’t even have to worry about it. They took care of everything once I found out about them (I paid for a few cycles of meds before I figured this out). You may not have BCBS of Texas, but just in case anyone does and reads this, I would like to pass this on…

Also, if none of this works for you, I did not have the money to pay for my cycles, I ended up getting a loan through the bank at a low interest rate. I also initially got a medical loan through I think Capital One or something like that. I figured I only have a certain amount of time to have children, but all the time in the world to pay the money back. I was able to pay off the two cycles it took to have my daughter right before she was born (I put absolutely all my money towards this until I had her).[/QUOTE]

Triessent is now Prime. I am going to try this but am thinking its not going to work as I have no medical or pharmacy coverage for infertility. But have my fingers crossed!


#8

I just googled Triessent, I see it is owned by Prime, but it seems like it still exist. I would just make sure you talk to the right people. I would call the Triessent number if at all possible.

I think you may be shocked, I was. I have no medical or pharmacy coverage for infertility. In fact, infertility meds are listed as specifically excluded under my policy. Triessent filed under my major medical, so once I met my deductible, my meds were covered at 100%. I still don’t understand it. The first time it worked, I thought it was a mistake. I finally reached someone at BCBS who said it wasn’t a mistake, but I still don’t understand the explanation. They filled numerous cycles of meds for me without question. It was awesome. I wish I still had that insurance.


#9

Is Prime/Trissent only under BCBS policy or all state policies? The state of texas recently changed from BCBS to United Health Care of TX…


#10

I think Triessent is specifically affiliated somehow with BCBS and would only apply to the BCBS of Texas policy. I have United now and haven’t found out any tricks like I did with the BCBS (but I am not through any state plan so yours may be very, very different).


#11

[QUOTE=houston]It must just be offered to your employer, but your employer may have declined the coverage. Even if it is offered, there are so many loopholes to jump through, for me, even though I am really infertile, I did not qualify (when my employer had this).

If you have BCBS of Texas (I think it must be “of Texas”) then you can call the speciality pharmacy (Triessent) and they will file the meds under your major medical and they will be covered. This saved me tons of money. I thought it was a mistake, I even called BCBS and they said my meds weren’t covered b/c they were specifically excluded under my policy. Then, I called BCBS and someone else told me they were. However, Triessent handles all of this for you and you don’t even have to worry about it. They took care of everything once I found out about them (I paid for a few cycles of meds before I figured this out). You may not have BCBS of Texas, but just in case anyone does and reads this, I would like to pass this on…

Also, if none of this works for you, I did not have the money to pay for my cycles, I ended up getting a loan through the bank at a low interest rate. I also initially got a medical loan through I think Capital One or something like that. I figured I only have a certain amount of time to have children, but all the time in the world to pay the money back. I was able to pay off the two cycles it took to have my daughter right before she was born (I put absolutely all my money towards this until I had her).[/QUOTE]

Still not sure if this still works or not. Triessent is now Prime. They wouldn’t tell me anything as far as prices without a script. So I had my RE office send over a script but it had micro Lupron on it so Prime sent it to Walgreens since it needs to be compounded. Walgreens called and for 55 vials of Bravelle it was $3089 - about $56 a vial, which is more expensive than Freedom. Anyways I called Prime back and asked if they could just give me a price for the Bravelle and I was told $3,000 and the lady specifically said “because it’s going under your major medical”. She couldn’t tell me though if it is $3,000 because that is the actual cost or if it is because that happens to be the exact amount of my yearly deductible/out of pocket max. So I guess when I am ready to order meds in a few weeks I will have to have my RE office send Prime a script for just the Bravelle and Menopur and see what they say … I hate not knowing and being able to plan!


#12

That is really strange. Why don’t you have your doctor send over the prescription for everything but the microdose lupron. Mine sent over everything, which they can do ahead of time. That way, you can go ahead and purchase it if you want (or they will hopefully tell you it is free after you meet your deductible). This worked for me on all meds except progesterone. I ended up ordering a lot of meds about a month in advance (b/c I had a cancelled cycle and I was trying to make sure I had everything on hand before I had to travel) and it was not a problem. Or, you could call them back and ask if it would be covered after you meet your deductible.


#13

[QUOTE=houston]That is really strange. Why don’t you have your doctor send over the prescription for everything but the microdose lupron. Mine sent over everything, which they can do ahead of time. That way, you can go ahead and purchase it if you want (or they will hopefully tell you it is free after you meet your deductible). This worked for me on all meds except progesterone. I ended up ordering a lot of meds about a month in advance (b/c I had a cancelled cycle and I was trying to make sure I had everything on hand before I had to travel) and it was not a problem. Or, you could call them back and ask if it would be covered after you meet your deductible.[/QUOTE]

I will have my RE office send another script over without the microdose Lupron but will wait until I go see them in a few weeks to officially get this ivf cycle started.


#14

I’ve worked for four employers in Texas and none of them had fertility coverage. I’ve recently applied for coverage on my own since I’m not working anymore, and I was denied because “you or your spouse has sought fertility treatment”. Unbelievable.
My friend who worked for IBM had excellent fertility coverage. Her employment may have actually been in another state, as she worked from home. Seems like states on the east coast have much better fertility coverage. Also seems that enormous corporations tend to have better fertility coverage.


#15

[QUOTE=hlaine]I will have my RE office send another script over without the microdose Lupron but will wait until I go see them in a few weeks to officially get this ivf cycle started.[/QUOTE]

IT WORKED!!! :woohoo: :cheer: I got 60 vials of Bravelle, 30 vials of Menopur and 1 Ovidrel for my $3,000 yearly deductible. It would have cost over $5,000 at Freedom Fertility, where I ordered my meds for my first IVF cycle. I am doing 2 egg banking cycles to do PGS testing, so my next round of meds should be free. I can’t believe this, it is so awesome!

They did want a prior authorization for the Ganirelix so not sure if that will go through or not. Should find out in a week or so.


#16

Great to hear! They had to do the same thing for me with the Ganirelex and it ended up being covered.


#17

[QUOTE=houston]Great to hear! They had to do the same thing for me with the Ganirelex and it ended up being covered.[/QUOTE]

I’m glad to hear the Ganirelex went through ok for you. I was thinking since it would be reviewed it would be denied. So happy these meds are covered. It seems like everything is really falling into place for my next IVF cycles! And thank you so much for sharing this info - I would never have tried without reading this forum.