CD4: Outta drug money

I knew it would happen, but not that it would happen so soon.

I've exhausted my IVF drug benefit. Holy crap. Somehow I've blown $25,000 worth of infertility drugs over the last 3 cycles plus the one that I'm currently in. Really? How can that be? I guess it works out when you figure what a single Gonal-F 900iu pen goes for.

But STILL!!!

So rather than this cycle's meds costing me about $450, it'll be $1050. I was within $1200 of maxing out the benefit but still needed 8 Gonal-F 900iu pens (valued at over $8000, according to the insurance company). They somehow figured that if a patient is within $1200 of their maximum benefit that the patient only needs to pay a portion (they said 30%?) of the remainder. Well somehow that 30% winds up being $791 to me. I don't know how they figure their math but 791 is NOT 30% of 8000. It still is a good deal for me, obviously, so I'm not griping, but I am shocked that this much money has been spent.

Now, by comparison, I've used $7900 of my $50,000 IVF benefit during the same time.

So $25,000 on drugs, and $7900 on 3 IVF cycles.

How can drugs cost 3 times more than the actual procedure?

It just doesn't make sense.

So on my call with the prescription drug carrier, they suggested I call my insurance company and ask if future drugs could be paid for through the major medical portion of my insurance company...that sometimes insurance companies will do this. It seems that I have a benefit for a procedure which requires medications, but no medication coverage. It's a conundrum.

My next call was my insurance company. I explained the situation to them and they said that they needed the "J codes" for my medications before they could tell me whether they'd be covered under major medical. It also might be that the drug money would come out of my remaining $43K benefit. OK. That works for me. I know that I can get meds for 4 cycles with $25,000 and that $7900 will do 3 IVF procedures. That's $33K total. I'm sure I could get 4 or 5 full cycles done for $43K. Maybe I need to negotiate a "frequent flyer" discount card with my RE? Buy 3 IVFs get one free?

I quickly fired off an email to the IVF clinic asking for the J Codes but it's after closing so I'll just have to call in the morning.

The craziness of IVF never seems to end.

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Endnotes: J-Codes are for injectible meds only (not oral). Here are the J-Codes for infertility drugs (all are "Status F", whatever that means) or you could look here.

Gonal-F: S0126
Ganirelex acetate 250mg: S0132
hCG 10K iu: J0725 (Novarel, Ovidrel, Pregnyl, Profasi)
Menopur: J3490
Follistim: J3590
Lupron: J1950