August 3, 2020 Ashley Struble

A Patients Fertility Coverage Journey

From a Specialty Pharmacy Liaison – My patient’s journey through infertility treatments started months ago. When it came time for her second round of medications she discovered her insurance plan had changed, leaving her without coverage for her upcoming treatments. The patient called the night before she was due for her next treatment, hoping I could get in touch with her husband’s HR department (his company provided the family health insurance) to see if there was anything the company could do. She thought the family should be grandfathered into the old insurance plan and continue to cover fertility treatments.

When I contacted the HR Department, they said her husband’s employer was bought out and the new company dropped fertility coverage from the plan. Luckily, because they were the only employees using the fertility coverage in the entire company, they allowed them to be grandfathered into the old insurance plan. However, it was going to take a team to get the old insurance coverage active again. That night just before close, I received authorization from the insurance company to reimburse the patient any out-of-pocket expense once they got everything squared away.

While this was great news for the patient, coming up with the money for the medication up-front was a hardship. Thankfully, we were able to put the charge onto an account and she did not to miss her treatment window. There was a lot of back and forth between the insurance company, her husband’s HR dept, and myself trying to get everything squared away for three weeks.

Unfortunately, the patient’s second treatment was not successful and she needed a third treatment. After spending a lot of time on and off the phone with the representative from HR and the insurance company, they were finally able to get it approved and receive a reimbursement from the insurance company for their out-of-pocket expenses. When I contacted the patient to update her and schedule medication delivery, she was extremely grateful for all the effort from all parties involved.

She stated, “I would have never received this type of treatment from any other pharmacy had I chose to fill elsewhere. I cannot thank you enough for the time you and everyone else have spent on this. It truly means so much to my husband and me.”