Coverage and Services FAQ

Yes, Progyny’s family building benefit was specifically designed to support everyone, including single parents by choice and LGBTQ+ individuals and couples. Contact your PCA to learn more about your family building options. 

Please contact your dedicated PCA for more information regarding your Smart Cycle balance and to discuss your options for utilizing your benefit. You can also view your Smart Cycle balance in your Progyny member portal. 

Progyny understands the importance of having diverse perspectives available for our members, and that some members may prefer to work with advocates with a shared gender identity. If you wish to request a male, transgender, and/or non-binary PCA, please make this known during your onboarding call or any time when speaking with your PCA. 

Progyny PCAs speak several languages, and we utilize a medical translation service for real-time (live) telephonic interpretation in over 200 languages. 

Each general treatment authorization is valid for 60 days (90 days for initial consultations) and covers all services listed for the associated treatment cycle found in the Explanation of Covered Treatments & Services section of this Member Guide. Certain services do require specific authorization. To learn more about services that require specific authorization steps, please visit http://nputilizationalliance.com/ or talk to your PCA. Request for authorization for covered services will be reviewed based on your individual submission and our written clinical policy. The request will be timely adjudicated and based on that review may be approved, denied, or partially approved or partially denied.

When you have used your full Smart Cycle allowance your lifetime benefits are considered exhausted. Initial consultations and other services can no longer be accessed, with the exception of any remaining storage renewals as determined by your plan. However, you will continue to have ongoing access to your dedicated PCA as long as you remain an employee under an eligible plan. Progyny can continue to provide support as you move forward with your family building journey. If you would like to continue treatment, your PCA can chat through your treatment options, provide educational resources, help you prepare for your appointments, as well as continue to provide emotional support and guidance throughout your family building journey. Once your Smart Cycle benefit has been exhausted, treatment costs will be incurred as an out-of-pocket cost to you. 

You have the option to opt out of the use of your Smart Cycle benefit and pay out-of-pocket for a service to save your Smart Cycle balance. Contact your PCA if you are planning to pay out-of-pocket for a service, as your PCA will work with your provider to arrange payment. You cannot retroactively request that authorizations be cancelled either to self-pay for services and conserve Smart Cycles, or if the services do not deduct any Smart Cycles. Please be sure to check your email and alert us immediately if your clinic requests an authorization for a service for which you wish to self-pay. In most cases, self-payment for treatment also means self-payment for medication. Once a claim is in process for medication and treatment, we are not able to cancel the authorization.  

In rare cases, a treatment cycle will need to be cancelled prior to completion. The following cases may arise:

• Cycles cancelled prior to retrieval (or aspiration) will not impact your Smart Cycle balance but will be subject to financial responsibility as determined by your medical insurance plan.
• Cycles cancelled after retrieval (or aspiration), [Cancelled Cycle (after aspi, before ferti)] Smart Cycle will be deducted from your balance.
• Cycles cancelled after fertilization due to no embryos available for biopsy, freezing, or storage will deduct 1/2 Smart Cycle. Please note, this partial cycle does not apply if your embryos are all aneuploid as all services in that case were rendered .
• Cycles converted to IUI or Timed Intercourse deduct 1/4 Smart Cycle.
• If you have further questions regarding cycle cancellation, contact your PCA.

In the case of cancellation, you will be subject to financial responsibility, as determined by your medical plan, for the services received up to the point of cycle cancellation. If you have further questions regarding cycle cancellation, contact your PCA.

If your treatment plan changes at any time contact your PCA immediately to obtain a new authorization. Changes will impact your Smart Cycle balance and out-of-pocket financial responsibility. Examples of changes in treatment plans may include:

• If your IVF freeze-all or IVF fresh treatment cycle is converted into a TIC by your provider
• If your IVF fresh cycle is converted into an IVF freeze-all cycle
• If your IVF freeze-all or IVF fresh treatment cycle is converted to an egg freezing cycle
• If your treatment is converted into a TIC and you do not want this service to impact your Smart Cycle balance, you have the option to pay for the service out-of-pocket. However, you will need to notify your PCA of this decision prior to the completion of your treatment. Progyny is unable to cancel authorizations once a claim from the clinic has been received. Contact your PCA with questions.

If your provider recommends a test, medication, or service that is not listed as a covered service under Progyny, please contact your dedicated PCA to confirm your coverage and discuss next steps. If the test, medication, or service is not covered under Progyny, you may be financially responsible.

For example, cholesterol, Pap smear, HPV, and other tests that are not specific to fertility are not covered under Progyny but may be covered under your medical insurance.

A reproductive endocrinologist (REI) is a fertility doctor who primarily focuses on female reproductive health and fertility to achieve a patient’s family building goals. A reproductive urologist (RU) is specialized in male reproductive health and supports male-factor infertility treatments to help an individual or a couple improve their fertility outcomes. Most patients begin their journey with an REI for an initial consultation and to undergo diagnostic testing, so they are better able to understand their family building options. After this step, they may be referred to a reproductive urologist if additional testing is required. A patient may also connect directly with a reproductive urologist (RU) without a referral, pending their specific journey. Your REI and RU must be in-network with Progyny to use your benefit.

Your Progyny benefit does not cover services for you to act as a donor or gestational surrogate for another person. Donors are those donating their eggs, sperm, or embryos to another person or couple. Donors are not the intended parent, not an intimate partner, and not carrying the pregnancy. Gestational carriers or surrogates are also not intimate partners and not the intended parents. Your Progyny benefit is for your own family building journey only and does not cover services for donor’s or surrogate’s treatment.

Your Progyny benefit includes coverage through your first positive pregnancy test. However, your reproductive endocrinologist may not refer you to your OB provider until week eight to twelve of your pregnancy. Pregnancy monitoring after that time should be billed as medical to your medical insurance plan. However, if your Progyny clinic provides pregnancy monitoring services prior to you transferring to your OB provider, it can be authorized and covered by your Progyny benefit.

Progyny may share your health information with healthcare providers who are involved in taking care of you, and they may in turn use that information to treat you. Your healthcare provider may also share your health information with other healthcare providers to whom you have been referred for further treatment. All such providers are required by law to protect the privacy of your health information.

Progyny may use your health information or share it with others so that we may obtain payment for your treatment or services. We share information about you with your health insurance carrier to obtain reimbursement, or to determine whether your insurance carrier will cover your treatment or services, or to obtain pre-approval for your treatment or services. We may share your information with other healthcare providers and payors for their payment activities. Such providers and payors are required by law to protect the privacy of your health information.

Progyny may also use your health information or share it with others to conduct our health care operations, for example, to educate our employees on how to improve the services they provide. We may share your health information with other healthcare providers and payors for certain of their health care operations. Such providers and payors are required by law to protect the privacy of your health information.

Progyny may use your health information or share it with others as required by law.

For more information, please see our Privacy Policy available at https://progyny.com.