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Skip Navigation LinksBecoming a Patient > Financing Infertility > Insurance > Sample Letter Forms > Letter Requesting Predetermination of Drug Coverage

Letter Requesting Predetermination of Drug Coverage

Thursday, May 17, 2012
RE: Predetermination of benefits for:
Group/Group Number:
ID Number:
Dear :
My
select
and I are considering infertility treatment. This procedure is necessary
to attempt pregnancy due to
.

Please provide me with a written response to each of the questions below:

  • Is there a pre-existing condition limitation?
  • Are separate referrals required for office visits, treatments cycles, medications and surgical procedures?
  • Which medications are covered by my medical plan?
    • For ovulation induction (OI)?
    • For intrauterine insemination (IUI)?
    • For in vitro fertilization (IVF)?
    • For gamete intrafallopian transfer (GIFT)?
    • For zygote intrafallopian transfer (ZIFT)?
    • For artificial insemination (AI)?
    • For embryo transfer (ET)?
  • If covered under a pharmacy benefit, what is the co-payment or deductible?
  • Is coverage dependent upon the use of certain pharmacies?
  • Is there a limit of any kind (dollars, time period, or number of cycles)?
  • If yes, are they lifetime limits or annual limits?
  • If none of the charges are payable, please identify the page in my contract where all charges are specifically excluded and the date the exclusion was added to the contract. If the charges are not excluded, I will assume they are payable.

I would appreciate a written response as soon as possible. If you have any questions for me, please call or Houston IVF at 713-465-1211. Thank you.

Sincerely,

Instructions

If fertility drugs are covered, you need to know what your out-of-pocket expenses will be for each drug used in your treatment. Insurers may specify different limitations for fertility medication prescriptions, exclude certain drug use with certain procedures, or exclude fertility medications completely. In addition, They may also limit the number of cycles you are eligible to have covered.

Fill out the form on this page, print it out, and send it to your insurance provider. While our Financial Counselors will do the same for you once you come to the office, some patients feel better knowing what their benefits are beforehand.