19 Questions to Ask Your Insurance Company Before Starting Treatment

At Sunfish, our mission is to bring confidence and clarity to a process we know can feel overwhelming. Figuring out what your insurance does (and doesn’t) cover can add a whole other layer of uncertainty when navigating fertility treatment, but the more you can learn ahead of time, the better prepared you can be for the costs and decisions ahead.

It’s best to get ahead of the questions that may come up, like How many cycles does my plan cover? Which medications are included, if any? What will I be responsible for out of pocket? These questions are much easier to answer and plan for before treatment begins than when a bill arrives.

Here’s a checklist of 19 questions to ask your insurance company before starting fertility treatment, so you can get a clearer picture of what to plan for and how to budget for out-of-pocket costs.

Coverage Questions

1. Which fertility treatments are covered under my plan? For example, is IVF, IUI, egg freezing, genetic testing, or embryo transfers part of the coverage?
2. Is prior authorization required? Check to see if your plan requires approval from your insurance company prior to coverage for certain medications, treatments, tests, or procedures, and who is responsible for submitting it.  
3. Are medications included in my plan? Fertility medications can vary in cost based on the doses you need and other factors. Ask which fertility medications are covered, whether they need to be filled through a specific or specialty pharmacy, and what your expected copays or coinsurance may be.
4. Is preimplantation genetic testing (PGT) covered? If you decide to undergo PGT to test embryos prior to implanting them, you may want to ask about which specific costs are included. Coverage can vary between the biopsy, testing of the embryos, and other related services, so ask about each component of the testing.  
5. Does the plan cover intracytoplasmic sperm injection (ICSI) treatment? Certain IVF treatment plans may involve ICSI, a fertilization technique that injects a single sperm directly into an egg. If you might be pursuing this treatment, ask whether ICSI is included or treated as a separate treatment, and if not, what portion of the cost you would be responsible for.

‍

Cost Questions

6. How much of my deductible applies to fertility care? It’s important to know whether or not fertility-related expenses count toward your regular deductible or whether your plan has separate rules for fertility-specific care. You’ll also want to confirm how much of your deductible you’ve already met for the year and which fertility services count toward it. This can give you a better idea of how much you may need to pay yourself before additional coverage kicks in.
7. Will I owe coinsurance even after I meet my deductible? If so, what percentage? Even though you’ve met your deductible, your insurance company may not cover 100% of your remaining costs. Ask what your coinsurance rate is for fertility care and whether it differs depending on the treatment, provider, facility, lab, pharmacy, or other service involved.
8. What is my annual out-of-pocket maximum, and do fertility treatment expenses count toward it? Your out-of-pocket maximum is generally the most you’ll pay during a plan year for covered, in-network services. However, there’s not a total guarantee that every fertility expense will count toward it. Ask which fertility-related deductibles, copays, and coinsurance payments count toward your out-of-pocket maximum, and which expenses do not.
9. Does my plan have a lifetime maximum of coverage for IVF or egg freezing cycles? Some fertility plans have a lifetime dollar maximum or other cap. It’s a good idea to ask about a lifetime maximum, and what it applies to: just IVF treatment, or medications, testing, or other fertility services? Additionally, you should understand what your next steps will be if you meet that lifetime maximum before you are finished with treatment.

Network Questions

10. Am I required to use certain pharmacies for my fertility medications to be covered? Fertility medications may be covered differently from other prescriptions, and some insurance plans require you to use a specific specialty or in-network pharmacy. Ask whether your plan has a preferred or required pharmacy for fertility medications and what could happen to your coverage if you fill a prescription elsewhere.
11. Can you help me identify in-network clinics to make sure my fertility care will be covered? Part of the clinic selection process, beyond location, involves finding an in-network fertility clinic that participates in your specific insurance plan. Your insurance company can simplify the process for you with a list of clinics that are in-network.
12. Do you have any trusted provider referrals within in-network clinics? To simplify your clinic and provider selection, you can ask your insurance company for a provider directory or a list of in-network fertility specialists. If your options are limited, find out how far you may need to travel to receive in-network care.
13. Are the labs, surgery centers, and other providers used by my fertility clinic also in-network? Choosing an in-network fertility clinic doesn’t necessarily mean every provider or facility involved in your treatment is also in-network. IVF and egg freezing can involve laboratory services, anesthesia, genetic testing, pharmacies, and other third parties. If you’ve chosen a clinic, you may want to ask for a list of outside providers they typically use so that you can verify them with your insurance carrier.  
14. What happens if I need fertility care from an out-of-network provider? Depending on where you are located, you may not have a choice but to travel far for a fertility provider or choose care from a closer out-of-network provider. Are there any out-of-network fertility benefits included with your plan, and will you have a separate deductible or coinsurance amount?

‍

Administrative Questions

15. What is the process of filing a claim to get fertility care covered? It’s important to find out upfront whether your clinic or provider will submit claims to your insurance company on your behalf or whether you need to submit any yourself. Make sure you’re aware of the typical processing timeline and any deadlines you need to meet.
16. What is the appeals process if coverage for part of my fertility care is denied? There could be even more twists and turns to the fertility treatment process, and a claim or prior authorization may not always be approved as expected. Ask what options you have to appeal a coverage decision, including how to submit an appeal, what supporting documentation may be required, and the deadline for doing so.
17. Will I be assigned a specific fertility case manager or other point of contact? Some insurance plans may offer access to a case manager, fertility benefits specialist, or another representative who can help you understand and navigate your benefits. Ask whether this type of support is available through your specific plan and, if so, how to contact that person directly. Our care coordinators can step in and help you here too.
18. Is it possible to get a reference number for this call and the information discussed? Before ending a call with your insurance company, ask for a reference or confirmation number for the conversation, if one is available. You may also want to record the representative’s name, the date and time of the call, and notes about the answers you received, just to be sure you don’t receive conflicting information the next time you call.
19. What should I do if my clinic and insurance company give me different information about my coverage? Fertility benefits can be complicated, and you may receive different information from your clinic and insurer about whether a particular treatment, medication, test, or provider is covered. Check with your insurance company about who is the right contact to resolve discrepancies and whether you can receive confirmation of your benefits or coverage decision in writing.