Possibilities Plan. Access to the care you need.

Transcription

1 Possibilities Plan If you do not have insurance or have insurance but lack coverage for infertility services and are concerned about the cost of infertility services, The Center for Advanced Reproductive Services has many self pay options for you to consider. From your new patient visit to completing an IVF cycle, our experienced financial counselors will work with you every step of the way. We offer the following programs priced as a package of services, or Case Rates, so you know what to expect financially before you begin your treatment plan. Below are Case Rate options you might consider over the spectrum of care from the diagnosis to treatment of infertility. New Patient Limited Consult Case Rate New Patient Basic Assessment Case Rate New Patient Full Assessment Case Rate Clomid IUI: Limited Monitoring Case Rate Clomid IUI: Full Monitoring Case Rate Gonadotropin IUI: Full Monitoring Case Rate Gonadotropin IUI: Expanded Monitoring Case Rate IVF Possibilities Plan Possibilities Plus Plans Freeze All Possibility Plan Gestational Carrier Possibility Plans

2 The Possibility Program Case Rate Waiver We (I) the undersigned understand that The Possibility Program products do not participate with any insurance plans and are designed for patients with no fertility treatment coverage. We (I) will have no insurance coverage for infertility treatment under this IVF Case Rate Plan, and we (I) will be responsible for all charges from services rendered to us (me) by Center for Advanced Reproductive Services, P.C. Furthermore, we (I) understand that insurance will not directly reimburse us (me) for any services received from Center for Advanced Reproductive Services, P.C. and that Center For Advanced Reproductive Services, P.C. will not accept reimbursement from insurance, including without limitation Medicare and Medicaid, for any services rendered to us (me) under the Possibility Programs. Therefore, we (I) agree that we (I) will not independently seek reimbursement for expenses from services received at Center for Advanced Reproductive Services, P.C. under the Possibility Programs, and we (I) will not directly submit to any insurance company for reimbursement. Possibility Program enrolled in: We (I) understand that all blood work in the Possibility Plans must be drawn and run in the Center s Farmington or Hartford offices. We (I) understand that the Possibility Program Case Rate we (I) are enrolled in is for one cycle only. We (I) must be financially cleared and re-enrolled for all subsequent cycles. Failure to do so will mean we (I) will revert to standard normal and customary fee schedule for services rendered. In the event our (my) cycle is cancelled we (I) understand that all services for the canceled cycle will revert to fee-for-service billing with a 25% discount and will be deducted from the original amount paid. The balance will then be refunded to us (me). As a self-pay, Possibility Program patient, we (I) understand that payment is due prior to starting medication, and payments on all outstanding patient balances are required prior to services. I (we) understand that Center for Advanced Reproductive Services, P.C. accepts CASH, Check, DISCOVER, MASTERCARD, AMEX AND VISA. We (I) understand that in the event our (my) account is turned over to a collection agency or to an attorney, we (I) will be responsible and hereby agree to be responsible for all associated fees, including attorney s fees and court costs. OUR (MY) SIGNATURE BELOW INDICATES THAT WE (I) HAVE CAREFULLY READ AND FULLY UNDERSTAND THE TERMS OF THIS WAIVER. Signature of Patient or Responsible Party Date Signature of Partner Date Note: Prices subject to change. The Center reserves right to end program at any time.

3 Possibilities Plan for New Patient Limited Consult If you do not have insurance or have insurance but lack coverage for the diagnosis of infertility services and are concerned about the cost of the initial patient consult, The Center for Advanced Reproductive Services has developed a New Patient Limited Consult Only Case Rate. This Case Rate includes an in depth consultative session with one of our board certified reproductive endocrinologist. No testing is included. Eligibility for this Case Rate is determined when our financial counselor verifies benefits with your insurance plan and it is determined that you do not have coverage for the services included in the Case Rate. If within six months after this consultation you decide you would like to move forward with a New Patient Assessment the amount paid for the New Patient Consult only can be put toward a buy up to the New Patient Assessment Case Rate The $199 Case Rate includes a complete review of your medical history and discussion with the physician.

4 Possibilities Plan for New Patient Basic Assessment If you do not have insurance or have insurance but lack coverage for the diagnosis of infertility services and are concerned about the cost of the initial patient assessment, The Center for Advanced Reproductive Services has developed a New Patient Basic Assessment Case Rate. This Case Rate includes the procedures necessary to diagnose the causes of infertility and to develop a treatment plan specifically for you. Eligibility for this Case Rate is determined when our financial counselor verifies benefits with your insurance plan and it is determined that you do not have coverage for the services included in the Case Rate. The $399 Case Rate includes the following services: New patient office visit with MD New Patient Ultrasound Patient intake and review of medical history New Patient Assessment Case Rate Does Not Include: Screening and infectious disease blood testing performed by third party lab. These are typically covered by insurance. Semen analysis which is typically covered by the male partners insurance Any additional testing

5 Possibilities Plan for New Patient Full Assessment If you do not have insurance or have insurance but lack coverage for the diagnosis of infertility services and are concerned about the cost of the initial patient assessment, The Center for Advanced Reproductive Services has developed a New Patient Full Assessment Case Rate. This Case Rate includes the procedures necessary to diagnose the causes of infertility and to develop a treatment plan specifically for you. Eligibility for this Case Rate is determined when our financial counselor verifies benefits with your insurance plan and it is determined that you do not have coverage for the services included in the Case Rate. The $1599 Case Rate includes the following services: New patient office visit New Patient Ultrasound Baseline endocrine testing (Day 3; TSH, Prolactin, P4) Sonohysterogram or HSG Follow up consult for treatment plan New Patient Assessment Case Rate Does Not Include: Screening and infectious disease blood testing performed by third party lab. These are typically covered by insurance. Semen analysis which is typically covered by the male partners insurance Hospital fees associated with HSG test

6 Possibilities Plan for Clomid IUI Cycle: Limited Monitoring If you do not have insurance or have insurance but lack coverage for Intrauterine Insemination (IUI) and are concerned about the cost of this procedure, The Center for Advanced Reproductive Services has developed a Clomid IUI: Limited Monitoring Case Rate. This Case Rate includes the procedures in your Clomid IUI treatment plan specifically for you. Eligibility for this Case Rate is determined when our financial counselor verifies benefits with your insurance plan and it is determined that you do not have IUI coverage for the services included in the Case Rate. The $549 Case Rate includes the following services: Endocrine testing Ultrasound monitoring (1-2) Cycle monitoring Intrauterine insemination Sperm preparation Canceled Cycles: In the event of a cancelled cycle all services will revert to fee-for-service billing with a 25% discount and will be deducted from the original amount paid. The balance will then be refunded. Fertility Medications: The cost of fertility medications is not included.

7 Possibilities Plan for Clomid IUI Cycle: Full Monitoring If you do not have insurance or have insurance but lack coverage for Intrauterine Insemination (IUI) and are concerned about the cost of this procedure, The Center for Advanced Reproductive Services has developed a Clomid IUI: Full Monitoring Case Rate. This Case Rate includes the procedures in your Clomid IUI treatment plan specifically for you. Eligibility for this Case Rate is determined when our financial counselor verifies benefits with your insurance plan and it is determined that you do not have IUI coverage for the services included in the Case Rate. The $1,499 Case Rate includes the following services: Endocrine testing Ultrasound monitoring Cycle monitoring Intrauterine insemination Sperm preparation Canceled Cycles: In the event of a cancelled cycle all services will revert to fee-for-service billing with a 25% discount and will be deducted from the original amount paid. The balance will then be refunded. Fertility Medications: The cost of fertility medications is not included.

8 Possibilities Plan for Gonadotropin IUI: Full Monitoring If you do not have insurance or have insurance but lack coverage for Intrauterine Insemination (IUI) and are concerned about the cost of this procedure, The Center for Advanced Reproductive Services has developed a Gonadotropin IUI: Full Monitoring Case Rate. This Case Rate includes the procedures in your Gonadotropin IUI treatment plan specifically for you. Eligibility for this Case Rate is determined when our financial counselor verifies benefits with your insurance plan and it is determined that you do not have IUI coverage for the services included in the Case Rate. The $1,975 Case Rate includes the following services: Endocrine testing Ultrasound monitoring (<4) Cycle monitoring Intrauterine insemination Sperm preparation Canceled Cycles: In the event of a cancelled cycle all services will revert to fee-for-service billing with a 25% discount and will be deducted from the original amount paid. The balance will then be refunded. Fertility Medications: The cost of fertility medications is not included. However, through our specialized relationship with the New Life Program and specific fertility drug manufacturers as well as other cost savings programs you will have access to medications savings ranging from $300- $600 per cycle. In addition, compassionate care medications are available for those who financially qualify.

9 Possibilities Plan for Gonadotropin IUI: Expanded Monitoring If you do not have insurance or have insurance but lack coverage for Intrauterine Insemination (IUI) and are concerned about the cost of this procedure, The Center for Advanced Reproductive Services has developed a Gonadotropin IUI: Expanded Monitoring Case Rate. This Case Rate includes the procedures in your Gonadotropin IUI treatment plan specifically for you. Eligibility for this Case Rate is determined when our financial counselor verifies benefits with your insurance plan and it is determined that you do not have IUI coverage for the services included in the Case Rate. The $3,399 Case Rate includes the following services: Endocrine testing (unlimited) Ultrasound monitoring (unlimited) Cycle monitoring Intrauterine insemination Sperm preparation Canceled Cycles: In the event of a cancelled cycle all services will revert to fee-for-service billing with a 25% discount and will be deducted from the original amount paid. The balance will then be refunded. Fertility Medications: The cost of fertility medications is not included. However, through our specialized relationship with the New Life Program and specific fertility drug manufacturers as well as other cost savings programs you will have access to medications savings ranging from $300- $600 per cycle. In addition, compassionate care medications are available for those who financially qualify.

10 The IVF Possibilities Plan IVF Possibilities Plan In many cases, couples who want to have a baby are treated with in vitro fertilization (IVF). IVF is a process where eggs are retrieved from the woman and are combined with sperm in a laboratory. One or more embryos are then transferred to the woman s uterus. The Center for Advanced Reproductive Services (The Center) offers all of the services required for IVF as well as advanced procedures including intracytoplasmic sperm injection (ICSI), assisted hatching, and embryo cryopreservation. During an IVF cycle, women are treated with medications to stimulate the development of multiple ovarian follicles to produce eggs for fertilization. The Center s medical team closely monitors this process using blood tests and ultrasounds. Mature eggs are retrieved using a surgical procedure with ultrasound. We then combine the retrieved eggs and sperm and transfer a limited number of embryos into the woman s uterus to achieve a pregnancy. How the IVF Possibilities Plan Works The IVF Possibilities Plan at The Center is open to all patients who do not have insurance coverage. Couples who are eligible pay $11,475 for one IVF cycle. The IVF Possibilities Plan includes one price for all cycle monitoring (blood work and ultrasounds), IVF Teach Class, egg retrieval, anesthesia for the egg retrieval, embryo transfer, ICSI (if appropriate, on all eggs retrieved), assisted hatching, embryo cryopreservation with one year of storage. Costs associated with the fertility work-up/checklist, diagnostic blood work and ultrasound, sonohystogram or HSG, outside monitoring, or medical treatment associated with an unsuccessful cycle (treatment for miscarriage, ectopic or biochemical pregnancy) are not included. Costs associated with oocyte, or sperm cryopreservation, TESA/MESA, facility fees and cycle medications are also not included. However, through our specialized relationship with the New Life Program and specific fertility drug manufacturers you will have access to medications savings ranging from $300-$600 per cycle. All patients at The Center are treated by our outstanding team of physicians, nurses and other specially trained patient care professionals. To learn more, contact one of The Center s Financial Service Representatives in Farmington at or Hartford at

11 Possibilities Plus Plans The Center for Advanced Reproductive Services (The Center) is very sensitive to the impact of the current economic situation on our patients. The impact is perhaps most significantly experienced in our In Vitro Fertilization (IVF) program where treatment options often involve services that may not be covered by insurance. We want to help. To that end, The Center is pleased to offer our IVF Possibilities PLUS program which will provide increased savings to self-pay patients based upon economic need. Financial need will be determined for couples by combined household income and single patient s individual income. Patients must provide a current tax return(s) to their Financial Services Representative (FSR). Determination guidelines are: Combined Household Income Or Individual: Cycle Fee(s): <$75,000 $8,575 $75,001 to $125,000 $9,975 >$125,001 $11,475 (standard Possibilities Plan) Costs associated with oocyte or sperm cryopreservation, outside monitoring, TESA/MESA, facility fees and cycle medications are not included.

12 Part 1 Freeze All or Retrieval no Transfer Cycles Possibility Plan IVF retrieval and embryology laboratory procedures including anesthesia Possibility Plan $9575 *Possibility Plus Plan $ Includes any required procedures (ie, ICSI, Assisted Hatching embryo cryopreservation, sperm prep for 1-2 samples, etc). Also includes: Ultrasound monitoring Endocrine testing Cycle monitoring Egg Retrieval Embryology procedures Anesthesia Facility fees not included. *Possibility Plus Program If you qualify and are enrolled in our Possibility Plus Programs your Financial Services Representative will work with you on fees specific to those programs. Part 2: Frozen Embryo Thaw Cycle FET includes all monitoring and procedures involved in a Frozen Thaw Cycle Possibility Plan $3975 Ultrasound monitoring Endocrine Testing Preparation of embryos for transfer Embryology procedures (Thaw, additional culture) Embryo Transfer First pregnancy test after transfer Anesthesia and facility fees are not included. Note: Prices subject to change. The Center reserves right to end program at any time.

13 Gestational Carrier Possibilities Plan For male individuals or couples, access to the care you need Screening $4275 Screening includes medical and psychological evaluation of gestational carrier and intended parents Not included in Screening: Standard blood testing (typically covered by insurance), FDA blood testing (typically covered by insurance) Fresh IVF $13,975 Fresh IVF includes a complete IVF cycle including any required procedures (ie, ICSI, Assisted Hatching embryo cryopreservation, sperm prep for 1-2 samples, etc.) First Frozen Embryo Thaw Cycle (FET) $4475 First FET includes all monitoring and procedures involved in a gestational carrier FET cycle. Second Frozen Embryo Thaw Cycle (FET) $2975 First FET includes all monitoring and procedures involved in a gestational carrier FET cycle. Canceled Cycles If there is a cancelled cycle, all treatment services will revert to fee-for-service billing with a 25% discount, will be deducted from the original and the balance will then be refunded. Services & Fees not included *Fertility medications; GC Compensation; Agency Fees; and Legal fees. *Fertility Medications Fertility medication costs are not included. However, through our specialized relationship with the New Life Program and specific fertility drug manufacturers, as well as other savings programs, you will have access to medications savings ranging from $ per cycle. Compassionate care medications are also available for those who financially qualify. Note: Prices subject to change. The Center reserves right to end program at any time.

14 Gestational Carrier Possibilities Plan Screening $4575 Screening includes medical and psychological evaluation of gestational carrier and intended parents Not included in Screening: Standard blood testing (typically covered by insurance), FDA blood testing (typically covered by insurance) Fresh IVF $13,975 Fresh IVF includes a complete IVF cycle including any required procedures (ie, ICSI, Assisted Hatching embryo cryopreservation, etc.) First Frozen Embryo Thaw Cycle (FET) $4475 First FET includes all monitoring and procedures involved in a gestational carrier FET cycle. Second Frozen Embryo Thaw Cycle (FET) $2975 First FET includes all monitoring and procedures involved in a gestational carrier FET cycle. Canceled Cycles If there is a cancelled cycle, all services will revert to fee-for-service billing with a 25% discount and will be deducted from the original amount. The balance will then be refunded. Services & Fees not included *Fertility medications; GC Compensation; Agency Fees; and Legal fees. *Fertility Medications Fertility medication costs are not included. However, through our specialized relationship with the New Life Program and specific fertility drug manufacturers, as well as other savings programs, you will have access to medications savings ranging from $ per cycle. Compassionate care medications are also available for those who financially qualify. Note: Prices subject to change. The Center reserves right to end program at any time.

15 IVF Financial Share Refund Program Administered by In Vitro Sciences, Inc. The IVF Financial Share Program includes up to three (3) fresh IVF and up to three (3) Frozen Embryo Transfer cycles until a live birth is achieved. If you do not give birth, you receive 70% of your fees for the Program refunded to you. You can apply at invitrosciences.com or call In Vitro Sciences at You must meet clinical and age criteria.