The Directors Guild of America-Producer Health Plan (“Health Plan”) partnered with Carrot Fertility (“Carrot”) to offer infertility benefits for covered participants and dependent spouses effective July 1, 2022.
The Health Plan recognized the challenges faced by many of our participants pursuing parenthood, and now covers qualified participants and their dependent spouses for medically necessary infertility treatment based upon a medical diagnosis of infertility. An eligible participant and the dependent’s spouse, if any, may each receive up to a total lifetime maximum benefit of $30,000 for infertility treatment. The $30,000 lifetime maximum benefit is an aggregate total of all covered services received from all in-network Carrot providers.
The Health Plan’s infertility benefit through Carrot provides coverage for medically necessary treatments for a medical diagnosis of infertility and access to infertility, family forming education, and pregnancy support, including:
For more information, please see Article IV, Section 9(n) of the Health Plan Summary Plan Description Section titled “What’s Covered Under Medical Benefits,” “Infertility,” The Health Plan SPD, and all updates, are available for free online at www.dgaplans.org, or you may contact the Health Plan to request a hard copy be sent to you at no costs. The Health Plan SPD shall control to the extent of any inconsistencies.
Carrot is available in 120+ countries, and services available may vary by geography, and local rules and regulations.
Following are examples of infertility treatments and services not covered under the new infertility benefit. Any of the following services must be paid for out of pocket:
Only a medical provider can provide a participant or their spouse with an infertility diagnosis, not Carrot or the Health Plan. Medical providers can determine infertility based on any commonly accepted medical guidelines, including but not limited to those issued by the Centers for Disease control or the American Society of Reproductive Medicine. Regardless of which of those guidelines is used, if you or your spouse has a medical diagnosis of infertility from your provider, you are eligible for the $30,000 lifetime benefit for family forming.
In understanding your infertility benefits, it is important to point out that the Health Plan is a not-for-profit, ERISA covered health plan that is subject to variety of federal laws, including IRS rules that affect the taxability of health benefits. These rules determine whether a benefit will be tax-free to you, or whether all or part of it might constitute taxable income to you. In order for the Health Plan to provide medical benefits to you on a non-taxable basis, the benefit must be a reimbursement for “qualifying medical expenses” (QMEs) as defined in Internal Revenue Code Section 213(d).
The definition of QMEs is complicated, but basically includes expenses for the costs of diagnosis, cure, mitigation, treatment or prevention of disease, or for the purpose of affecting any part or function of the body. The expense must be primarily to treat or prevent a physical or mental disability or illness.
Under the IRS rules, QMEs do not include expenses incurred by donors or gestational surrogates. Similarly, QMEs do not include adoption expenses. It would only include expenses incurred by you and your dependents.
This means that if you or your spouse receive a medical diagnosis of infertility from your provider, you qualify for the $30,000 lifetime benefit ($60,000 if both of you are diagnosed with infertility).
The following benefits are still available through Carrot, without cost, regardless of whether you have an infertility diagnosis:
After you’ve created your Carrot account at app.get-carrot.com/signup, download the Carrot mobile app to gain access to Carrot’s full suite of resources on the go. Participants everywhere can view their available Carrot Card balance, benefit guide and provider finder or even visit with a Carrot expert from the convenience of their phone or tablet.
Please note the following important considerations applicable to the infertility benefit:
Beginning April 1, 2024, all eligible fertility-related prescriptions must be filled through Carrot Rx for your eligible medications to be covered with Carrot funds. CarrotRx has partnered with Alto Pharmacy. Your medications will need to be filled directly with Alto Pharmacy and communication on the status of your prescriptions will be coming from Alto as well. When medications are received, it will state it is from Carrot Rx (powered by Alto) on the box.
If you currently receive your fertility-related medications through a pharmacy other than Carrot Rx, you will have until May 15, 2024 to transition your prescriptions to Carrot Rx. After May 15, 2024, expenses you submit from non-Carrot Rx pharmacies will be denied.
Carrot Rx offers savings of up to 40%, as well as price matching on most fertility-related medications and next-day or same-day delivery when needed. With Carrot Rx, you also get 24/7 access to certified clinicians who can answer any questions you might have about your medications.
For more information about getting your fertility-related medications with Carrot Rx, including frequently asked questions, exceptions to the Carrot Rx-only prescription policy and a step-by-step guide to ordering your prescriptions through Carrot Rx, click here to download a helpful pdf.
Have additional questions about your Carrot benefit?
Visit www.get-carrot.com/employee-support to connect with the Carrot Care Team.
