COST ESTIMATION DEPARTMENT ARG 2018

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1 Please read the accompanying information! These prices are indicative and can vary because they are subjected to indexing. This cost estimation is limited and does not include additional medical services by other departments that are not shown in this document, nor the costs of blood analyses during your treatment. The total price of your treatment depends on the different performances (type, complexity) and their number during your treatment. IVF/ICSI CYCLE COST ESTIMATION DEPARTMENT ARG 2018 Ultrasonography Z SOET-Technology Follicular puncture Z Flat rate complex evaluation of refractory infertility L Embryo transfer Z Lab expenses IVF/ICSI (a) L Medication (b) ; (c) Z (a) These expenses will be dropped when the patient has a valid reimbursement form of a Belgian health insurance (6 IVF/ICSI cycles refunded) (b) Only for patients with a valid reimbursement form of a Belgian health Insurance or equivalent: These expenses will be charged if an ongoing treatment is cancelled for a non-medical reason. (c) These costs are reduced to ± 60 for a patient with a valid reimbursement form of a Belgian health insurance. Patients without a Belgian health insurance should contact their own insurance about regulations for purchasing their medicines. Additional lab techniques IVF/ICSI CYCLE Biopsy of the embryos for PGD/PGS L 530 PGD Pre-implantation genetic diagnostics (d) Z PGS Pre-implantation genetic screening (d) L MOAT Mouse oocyte activation test L 510 AOA Artificial activation of oocytes L 315 (d) These costs include the laboratory cost for the performance of the genetics department. The cost for PGD for monogenic hereditary disorders is case dependent. Insemination IUI CYCLE Ultrasonography Z IUI Insemination Z Medication (e) Z (e) These costs are reduced to ± 25 for a patient with a valid reimbursement form of a Belgian health insurance. Versie:01/10/2016 ARG-F Kostenraming 2017 ARG voor patiënten (ENG) 1/5

2 Sperm analysis Lab costs sperm analysis without freezing (h) L 50 - Lab costs sperm analysis + freezing (f); (h) L Lab costs TESE/MESA (g); (h) L Lab costs TESE/MESA + freezing (f); (g); (h) L Lab costs Electro-ejaculation (h) L Lab costs Electro-ejaculation + freezing (f); (h) L (f) The costs for freezing includes the first year of preservation starting from the date of freezing. (g) These costs are only for the analysis of the tissue in the lab, they do not include the costs of the surgery. (h) These costs do not apply for oncological patients with a Belgian health insurance who fulfil the conditions of the fertility preservation convention. In the latter case, the storage time of 10 years is included. Donor sperm An order of donor sperm is only processed after payment of an advance. When your screening file is approved, you will receive the request for a bank transfer, by mail or post. After receipt of the payment, it takes one month before the donor sperm is available. Donor sperm 1 straw (i) L 175 Administrative expenses to ordering donor sperm (including storage costs) L 200 (i) The donor sperm is stored as long as you are in treatment. If your treatment stops, or you have reached the age limit for treatment, then the straws are no longer available to you. Orders are standard per 3 or 6 straws. Exceptions need to be decided by the treating physician. This price is an indication and can vary because of availability of the donors. Freezing/prolonging the storage time Freezing of gonadal tissue or vitrification of oocytes including the first year of storage (j); (k) L 150 Frozen sperm, gonadal tissue or oocytes: Prolonging the storage time with 1 year L 50 Frozen sperm, gonadal tissue or oocytes: Prolonging the storage time with 3 years L 150 (j) For patients -18 years old, the retention period of 10 years is included (k) These costs do not apply for oncological patients with a Belgian health insurance who fulfil the conditions of the fertility preservation convention. In the latter case, the storage time of 10-yearsis included. Others HyFoSo (Hystero foam Sonography) Z 145 Endometrial biopsy (Pipelle) Z 65 Versie:01/10/2016 ARG-F Kostenraming 2017 ARG voor patiënten (ENG) 2/5

3 ACCOMPANYING INFORMATION COST ESTIMATION ARG 2018 FOR PATIENTS WITH A BELGIAN HEALTH INSURANCE OR ASSIMILATED PATIENTS (E112/S2) On this estimation of costs both lab and hospital costs are indicated. The hospital expenses are indicated with the letter Z, the lab costs with the letter L. For some hospital costs there are different week and weekend (or bank holiday) rates. All rates are indicative and can vary because of indexation. Patients with a Belgian health Insurance are refunded a large part of the hospital expenses and only a small part (the patient share) is to be paid by the patient himself. The rates mentioned on the cost estimation are total costs (patient share + the part funded by the Belgian health insurance) The IVF/ICSI lab costs are paid by the Belgian health Insurance as well, in case you have a valid reimbursement form. In case you don t (no longer) have this form, you will receive an invoice by post. To avoid unnecessary invoices, it is important that you hand over the reimbursement form at our department before the start of the treatment. Additional lab techniques, semen analyses and management costs concerning freezing (independently of the convention) are not refunded by the Belgian Health Insurance. For these costs you will always receive an invoice at home. Patients who wish to order donor semen (after approved screening procedure) need to pay first an advance by bank transfer. They will receive a transfer request by post or . Only after receiving the payment, the donor sperm is ordered. To prevent your treatment from being postponed, we recommend that you carry out the bank transfer as soon as possible. Check each request very carefully on which account the payment should be done and mention in each case the correct payment reference. This payment is only an advance. The actual invoice will be send by post at a later date. On Patients who have a E112/S2 document, have to present this themselves, at least 2 months before oocyte pick-up at the reception desk K1-K2 of the UZ Ghent hospital, and have to clearly mention this at the department of reproductive medicine (reception) Versie:01/10/2016 ARG-F Kostenraming 2017 ARG voor patiënten (ENG) 3/5

4 ACCOMPANYING INFORMATION COST ESTIMATION ARG 2018 FOR PATIENTS WITHOUT A BELGIAN HEALTH INSURANCE OR ASSIMULATED INSURANCE IVF/ICSI CYCLE Each patient without a Belgian health Insurance that starts an IVF/ICSI cycle and whose follicular puncture will take place in the UZ Ghent hospital, will have to pay an advance of at the latest on the day of the follicular puncture. This advance can be paid with credit card (VISA, Maestro, Master card) at the reception desk K1-K2 of Attention: In consideration of the law on the restriction of cash payments above 3.000, only 10% may be provided cash. (= 380 cash at an amount of ) When the advance is not paid, the follicular puncture will not take place. Patients without Belgian health insurance whose follicular puncture takes place in another hospital, will have to pay an advance of at the latest on the day of the embryo transfer. When the advance is not paid, the embryo transfer will not take place. Embryo transfer (cryo) Each patient without Belgian health insurance starting an embryo transfer (cryo), will have to pay an advance of 200 at the latest on the day of the transfer. When the advance is not paid, the insemination will not take place. Insemination (IUI) Each patient without Belgian health insurance starting an IUI treatment, will have to pay an advance of 300 at the latest on the day of the insemination. When the advance is not paid, the insemination will not take place. Donor sperm Patients who have an approved screening file wish to order donor sperm, will have to pay an advance by bank transfer. They will receive a transfer request by post or . Only after receiving the payment, the donor sperm is ordered. To prevent your treatment from being postponed, we recommend that you carry out the bank transfer as soon as possible. Versie:01/10/2016 ARG-F Kostenraming 2017 ARG voor patiënten (ENG) 4/5

5 Insurances Check each request very carefully on which account the payment should be done and mention in each case the correct payment reference. This payment is only an advance. The actual invoice will be send by post at a later date. On Patients who think their Insurance will pay (partially) the costs of a treatment, have to contact the insurer and the reception desk of the UZ Ghent K1-K2 themselves. This can be done by phone or . The patients themselves have to gather the necessary documents and if necessary make sure that these are filled in and signed by the treating physician. Approval by the insurance needs to be presented preferably by the patients themselves at the reception desk K1- K2 of the UZ Ghent. This also can be done by phone, or fax. Phone: 0032 (0) aanmeldeneninschrijvingen@uzgent.be Fax: 0032 (0) In each case, clearly mention your name, date of birth en patient number. At the reception desk K1-K2 your insurance status will be checked out and they will explain the procedure to follow. This procedure also applies for patients who visit the UZ Ghent hospital for an embryo transfer. For treatments where you need to pay an advance (IVF/ICSI, IUI), applies that the treatment will not be carried out, if the payment is not in order. So check before you come to the hospital whether you will be able to make the payment. (cash or credit card that allows you to pay the amount requested) If you want to pay with credit card, also check to make sure that your credit limit is high enough. Attention: In consideration of the law on the restriction of cash payments above 3.000, only 10% may be provided cash. ( = 380 at an amount of ) Purchase of medicines in the pharmacy of the hospital The retrieval of medications from the hospital pharmacy can be paid only by credit card. (Visa, Master card, Maestro) No cash can be received. For Financial questions regarding your UZ invoice, please contact the financial department of the hospital. By calling 0032 (0) or via mail facturatie.patienten@uzgent.be For Financial questions regarding the services provided by the department reproductive medicine, please contact: arg@uzgent.be I hereby state that I have been informed of the cost estimation on././. Name in block letters + signature patient Name in block letters + signature partner Versie:01/10/2016 ARG-F Kostenraming 2017 ARG voor patiënten (ENG) 5/5

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