Several employers in our area have partnered with Progyny to provide a comprehensive fertility benefit. Progyny is a third-party insurance company that manages an inclusive fertility benefit plan known as a “Smart Cycle.”
Based on your employer’s selected plan, each employee gets a certain amount of Smart Cycles and each fertility treatment takes up a portion of that Smart Cycle. For example, a round of IVF may take up 75% of a Smart Cycle, while sperm freezing may only use 25%. Treatment percentages vary by plan and employer, so it is important to learn what your coverage specifically is.
Every employee that has Progyny is assigned a Patient Care Advocate (PCA) that they work with directly at Progyny. Once you call SRM to schedule your appointment, you will be given the contact information for your PCA that is assigned to your employer. Below are some of the most commonly asked questions as it relates to Progyny Benefits. Your PCA can answer any additional questions you may have.
How do I know if I have Progyny benefits?
Our financial counselors at SRM are able to assist you in finding out if you have Progyny benefits.
Do I need preauthorization from Progyny prior to my initial appointment?
Yes. Once you contact SRM for an initial consultation, you will be given the number to your dedicated PCA. They will assist you with your preauthorization. A referral from your PCP or OB/GYN is not required.
What is a Smart Cycle?
A Smart Cycle is Progyny’s benefit “currency”. Rather than a dollar maximum, your Progyny benefit includes a certain number of Smart Cycles and each treatment is valued as a portion of a Smart Cycle. The Smart Cycle benefit is a lifetime benefit. Your PCA will review with you the number of Smart Cycles you have, how much each treatment cycle is worth, any exclusions to your plan, and what your estimated out-of-pocket costs would be based on your deductible or coinsurance.
Are all Smart Cycles the same?
Smart Cycles may vary by employer so it is important that you review your benefits with your PCA.
If I use Progyny benefits, will the HR team, upper-management, or my co-workers know that I am undergoing fertility treatment?
No one at your place of work will know that you are pursuing treatment unless you tell them yourself.
Why am I receiving bills from Progyny?
Progyny will bill you directly for any financial responsibility based on your medical plan so it is important to touch base with your PCA prior to initiating treatment regarding out-of-pocket costs you may have.
What happens if I exhaust my Smart Cycle benefit?
Smart Cycle benefits through Progyny have a lifetime maximum. Once you have used your allotted cycles, you become financially responsible for treatment. Our financial counselors can assist you to see if you have fertility benefits through traditional medical insurance and can help you look into options for paying self-pay, if needed.
- Do I need preauthorization from Progyny to begin treatment?
Yes. SRM will request any necessary authorizations for treatment on your behalf.
- Is my new patient visit with the fertility specialist covered by Progyny?
This first consultation is included in Progyny plans and is not a part of a Smart Cycle.
DIAGNOSTICS AND TESTING
Progyny coverage includes a diagnostic testing bundle, which is a separate benefit from a Smart Cycle. Be sure to review which diagnostic tests are covered under this benefit as you may decide to have tests completed at your initial consultation at SRM.
Potential testing may include the following:
- Antimullerian Hormone (AMH)
- Follicle Stimulating Hormone (FSH)
- Carrier Screening
- Antral Follicle Count Ultrasound
- Hysterosalpingogram (HSG)
- Saline Infused Sonohysterogram (SIS)
- Office Hysteroscopy (OH)
- Semen Analysis
Your PCA will review with you the number of Smart Cycles you have and what percentage each fertility treatment uses.
Treatment recommendations may include:
- Intrauterine Insemination (IUI)
- IUI using donor sperm
- Sperm Freezing
- Egg Freezing
- In Vitro Fertilization (IVF)
- IVF with Intracytoplasmic Sperm Injection (ICSI)
- IVF with Preimplantation Genetic Testing (PGT)
- Frozen Embryo Transfer
- IVF with Donor Egg
- Gestational Surrogacy
- Storage Fee for Frozen Specimen
Treatment cycles often require the use of injectable and specialty medications. Review with your PCA whether you have benefits under Progyny Rx which requires you to use a mail-order specialty pharmacy.
The following specialty medications are commonly prescribed during fertility treatment:
- Human Chorionic Gonadotropin (HCG)
- Gonal F
- Leuprolide Acetate
- Progesterone in Oil
- Progesterone in Ethyl Oleate