University of Utah - Human Resources

UNIVERSITY OF UTAH EMPLOYEE HEALTH PLAN COVERAGE FOR FERTILITY BENEFITS

Effective July 1, 2021, the University of Utah Employee Health Care Plans will add coverage for a limited amount of fertility assistance and treatment. That coverage is described here. If you have questions regarding the coverage, contact Regence or HR.

FERTILITY ASSISTANCE AND TREATMENT

Provider: University of Utah Hospitals and Clinics, In-Network and Out-of-Network

After In Network Deductible, the Plan pays 75% of the first $6,000 Billed by the Provider. You pay 25% of the first $6,000 Billed by the Provider and any balance billed over $6,000.

Benefit Limit: $4,500 per Claimant lifetime. Separate lifetime limit for Prescription Medications – see Prescription Medications section. This benefit limit is combined with the limit for Oncofertility. In no event will a Claimant be eligible for more than $12,000 in a lifetime.

Services and supplies for assisted reproduction, including associated office visits. Services for the diagnosis and treatment of a medical condition that results in infertility is covered under the Medical Benefits section. Your out-of-pocket costs up to $1,500 apply to the In Network Out-of-Pocket Maximum.

For example, your procedure cost is $10,000. The Plan will pay $4,500. You will pay $5,500 (including your deductible) and $1,500 of your payment will count toward your out-of-pocket maximum. However, if your procedure cost is $3,000, you will pay Your deductible and the Plan will pay 75% of the remaining balance and you pay the balance. In the latter case, the full amount you pay will apply toward your out-of-pocket maximum. You will still have funds remaining for future fertility procedures.

PRESCRIPTION MEDICATIONS

Prescription Medications for fertility and assisted reproduction covered up to a maximum of $3,000 per Claimant lifetime. Your out-of-pocket costs up to $1,000 apply to Your Prescription Drug Out-of-Pocket Maximum.

ONCOFERTILITY SERVICES (FERTILITY PRESERVATION PRIOR TO CANCER TREATMENT)

Provider: University of Utah Hospitals and Clinics, In-Network and Out-of-Network

After In Network Deductible, the Plan pays 75% of the first $16,000. You pay 25% of the first $16,000 and any balance remaining after the Plan's payment.

Benefit Limit: $12,000 per Claimant lifetime. Separate lifetime limit for Prescription Medications – see Prescription Medications section. This benefit limit is combined with the limit for Fertility Assistance and Treatment. In no event will a Claimant be eligible for more than $12,000 in a lifetime.

Services and supplies for fertility preservation for a Claimant undergoing cancer treatments that may affect the Claimant's future fertility. This benefit combined with the benefit for fertility medications has a combined limit of $15,000. In the event a Claimant has exhausted their lifetime limit for Prescription Medications and have paid out of pocket for Prescription Medications for fertility medications, and still have unused lifetime dollars available under Medical limit, the Claimant may request reimbursement for their out of pocket expenses for fertility medications from their unused Medical fertility treatment dollars, up to the full lifetime limit. It is the member's choice to apply unused dollars from the Medical to Prescription Medications. Members must submit a claim including pharmacy receipts showing date of purchase, prescription drug number, name and dose, and amount paid for the medications, along with any other requested information and documents in order to request reimbursement.

FREQUENTLY ASKED QUESTIONS REGARDING THE FERTILITY BENEFIT

Fertility Treatment and Coverage
Does benefit cover both IUI and IVF?

Yes. The fertility benefit will cover both IUI and IVF, as well as other fertility-related services and prescription drugs that are currently excluded under the health plan.

Is diagnostic testing covered?

Some diagnostic testing may be a standard benefit and covered as a medical benefit already (not using funds from the fertility benefit). However, if the service is billed with an infertility diagnosis and is a type of service that would indicate it is related to infertility treatment, the claim would count towards your fertility benefit (for example, an ultrasound for diagnostic testing could be billed to the medical benefit and after fertility treatment has started an ultrasound outside of a standard package bundle would count towards your fertility benefit).

Are male testicular sperm extractions covered?

Yes, as long as the male is covered under the health plan. Any services provided for a male will be billed under his health coverage and not the female's coverage.

Are surrogacy benefits covered?

No. Surrogacy services are not covered.

Are there exclusions? Such as Genetic Testing? Cryopreservation? Donors?

Genetic testing is covered as a medical benefit and may require a prior authorization. Cryopreservation is covered under the fertility benefit (you may be required to pay for the service and then request reimbursement). The plan does not cover the harvesting of embryos/egg/sperm from a donor not covered by the health plan and does not cover the purchase of embryos, eggs, or sperm.

Does this benefit cover storage fees for embryos/egg/sperm?

Yes. An employee may choose to apply their benefit toward payment of new or current storage fees. The employee may need to pay the fees and then request reimbursement for fees incurred July 1, 2021 and later. Regence's Reimbursement Request form is HR's forms web page.

Are tubal reversals and/or vasectomy reversals covered?

Reversals are not a covered medical or fertility benefit.

Criteria for Treatment Coverage
Is there certain criteria that need to be met before treatment can begin?

No. Employees can use the fertility benefit at any time they are ready. The larger Oncofertility Benefit (fertility preservation benefit for employees going through cancer treatment) will require the provider to provide certification that the individual is going through cancer treatment.

Are there requirements before moving onto IVF (i.e exhaust other treatment options)?

No. The benefit may be used any way the individual wishes to use it. Individuals are encouraged to consult with their physician to determine the best treatment options for them.

Are there marital status restrictions (i.e. intended parents male/female and intended parents of same sex)

No. The only restrictions are that the individual receiving the treatment be covered by the health plan.

Employee Benefits Criteria
Is benefit just for employee or is there coverage for children or spouse?

The benefit will cover all members of an employee's family who are enrolled in the health plan.

Is there a minimum age and/or age cut off?

The plan does not have any age limits. Check with your provider's office to see if they have limits.

If two University employees are enrolled in the health plan and cover each other, do they get $15,000 total benefit?

Yes, while an individual has dual coverage under a University employee health plan that includes the fertility benefit, the individual will have $9,000 for medical services provided to them and $6,000 for prescription medications prescribed to them.

Is the lifetime maximum per family or per person?

The lifetime maximum is per covered individual.

If an employee leaves and comes back does the benefit start over?

No. The benefit is a lifetime maximum for enrollment in any of the University's plans (including the academic campus plan and the hospitals and clinics plan).

If an employee transfers from a UUHC position to a position with academic campus, what happens to their benefit if already used?

Employees who transfer between UUHC and academic campus will not have a new lifetime benefit. The lifetime benefit is for all employment through the University of Utah.

If coverage is per member, can both employee and spouse combine the $7,500 to cover the cost of treatment?

A male and female partner may not share their benefit to allow the other to have more than the $7,500 maximum. Services billed or medications prescribed to an individual will apply that that individual's maximum.

Billing and Operationalizing
Is the benefit paid based on service being done or diagnosis?

The benefit will be paid based on the service provided and amount billed by the provider. Any services or medications that could be covered as a medical benefit (are not billed with an infertility diagnosis or are a fertility-related treatment) will be covered as a medical benefit and will not count against the lifetime maximum fertility benefit.

Would this be global? If global billing, will there be a discounted rate for IVF/FET cycles and patients will be responsible for the amount left after their benefit exhausts?

Some providers will bill Regence for services and Regence will pay the provider for eligible services. Other providers may require you to pay up front and then request reimbursement for eligible expenses from the health plan. Individuals are encouraged to discuss treatment costs with the clinic's financial counselor. Payment by the plan will be made based on the amount billed by the provider for covered medical services or medications prescribed to an individual enrolled in the health plan.

Are individuals required to go to a specific provider? A network provider? How would an out of network benefit be administrated?

Individuals are not required to go to a network provider. If the provider is willing to bill Regence for the services, Regence will provide payment directly to the provider. If the provider requires payment from the individual and will not bill insurance, individuals will be required to pay for the services prior to treatment and then request reimbursement for eligible services and medications from the health plan.

Is this separate from the cancer cost or is this going to replace that?

An individual who will be receiving cancer treatments that may affect future fertility may use an additional $7,500 for fertility preservation measures after confirmation of cancer treatment has been provided to Regence. This means the individual will be eligible for a total of $12,000 for medical services and $3,000 for fertility-related medications.

Since cycles are more than that how would this be applied?

Payment for any amounts over the health plan's lifetime maximum must be paid by the individual.

Who is tracking what is used/left of the benefit amount?

Regence is tracking the amount used for medical-related fertility benefits and the plans' pharmacy benefit manager (Regence for academic campus and UUHP for UUHC employees) is tracking the amount used for fertility-related prescription medications.

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