There are various levels of infertility coverage that may be offered to you by your insurance carrier. They are each significantly different & specific as to the services that will be covered. Each of the coverage levels listed below will be limited to either an attempt limit and/or a dollar amount limit. These limitations vary from plan to plan.
No Infertility Coverage and Self-Pay Discount Packages
Plans that specifically exclude infertility coverage will not cover office visits, labs, ultrasounds or treatments associated with an infertility diagnosis. For those whose insurance does not pay for these services, or for patients without insurance, we offer discounted self-pay packages for our various services.
(Excludes certain Aetna policies, please contact billing for further information/description) Plans that offer basic coverage will generally cover diagnostic testing before and after a diagnosis of infertility has been established. Services that are usually covered under basic coverage are:
Blood tests Office Dx
Comprehensive Infertility Coverage
Generally comprehensive coverage is offered to small group policies. These plans will cover diagnostic testing and Artificial Insemination (IUI) only. Services generally covered under this benefit level are:
Diagnostic ART prep
Artificial insemination (IUI)
Advanced/ART Infertility Coverage
This is the highest level of infertility coverage offered. Plans that offer Advanced/ART coverage will generally cover services such as:
Diagnostic ART prep
Artificial insemination (IUI)
In Vitro Fertilization (IVF)
NJ Infertility Mandate
Covers all of the services listed above (Basic, Comprehensive and Advanced). Patients covered under the NJ State Mandate MUST do lesser before greater (3 IUIs before IVF). Artificial insemination (IUI) attempts are unlimited and In Vitro (IVF) is limited to 4 attempts per lifetime. Infertility services have a maximum age limit of 45 years old (patient will only be covered until the 45th birthday).
*Please keep in mind that this information is a general reference ONLY & coverage may vary from plan to plan.
URA participates with most major insurance carriers (URA does NOT participate with Medicaid or Horizon Advance EPO). Below is a listing of these carriers, as well as, authorization and/or referral requirements.
Aetna US Healthcare Members:
If you are insured by AETNA and are eligible for infertility benefits you will either be required to register with Aetna’s Women’s Health Services Dept. or will be required to obtain a referral from your PCP in order to utilize your full benefits. Unfortunately, there is no set protocol as to what certain Aetna plans will require; therefore we recommend that you contact Aetna for a description of your infertility benefits as well as any requirements that may apply to your particular plan.
Aetna has a dedicated infertility program that will manage ALL of your visits including your initial consultation to our office. It is very important you contact them for your initial authorization and/ or referrals, failure to do so will result in an additional out of pocket expense to yourself. Unfortunately, Aetna will not allow URA or any other office to request registration/ initial authorization or referrals; therefore it is solely your responsibility to obtain proper authorizations for your visits. Aetna patients MUST register with Aetna’s Women’s Health Services: 1-800-575-5999
*** Please be aware that your initial enrollment in the program is not sufficient for any further testing or treatment. They will need to be contacted for authorization prior to any additional service(s) or procedures being performed. ***
Any testing to be done on male partners will require a specific referral issued by their PCP (if referrals are required by your plan). Authorizations from the Women’s Health Services Dept. will not be required. Any authorization issued to the female will NOT cover testing to be done on the male partner.
Sperm isolation (complex):
Upon requesting referrals from the PCP’s office, you must request that both of the procedure codes indicated above be on the referral. Aetna will NOT cover this testing if these service codes are not specifically indicated on the referral.
If you are insured by OXFORD and are eligible for infertility benefits you will either be required to enroll with OPTUM HEALTH. We recommend that you contact Optum Health for a description of your infertility benefits as well as any requirements that may apply to your particular plan.
Oxford/ Optum Health has a dedicated infertility program that will manage ALL of your visits including your initial consultation to our office. It is very important you contact them for enrollment, failure to do so will result in additional out of pocket expenses to you. Unfortunately, Optum Health will not allow URA or any other office to request enrollment or referrals; therefore it is solely your responsibility to obtain proper authorizations for your visits. * If you are eligible for Comprehensive/ IUI benefits there are limitations that apply: For patients under 38 yrs old- 4 IUI cycles, patients 38-40 yrs old- 2 IUI cycles and patients over 40 yrs old- 1 IUI cycle.
Oxford patients MUST enroll with Optum Health: 1-877-512-9340
GHI/ Emblem Health Members:
If you are insured by GHI/ Emblem Health and are eligible for Advanced/ IVF benefits you will need to meet certain criteria before being approved/ authorized for an IVF cycle. A Hydrosonogram (saline sono) is required, as well as, Hysterosalpingogram (HSG). It is required for patient to do 6 IUI CYCLES for members under 35 or 3 IUI CYCLES for members 35 and over. You will also need to provide 2 RECENT SEMEN ANALYSIS (male partner) if ICSI is being requested.