Fertility treatments: Standalone benefit options and TrumpRx 

Soon after taking office, President Trump signed an executive order aimed at making fertility treatment more accessible and affordable. Recently, the White House issued what amounted to a progress report, generating a fair amount of buzz. In addition to news about discounted pricing for fertility medications, it stated that regulators would soon issue new rules making it easier for employers to offer financial support for fertility treatment as a standalone benefit. For employers that don’t already provide coverage for fertility treatment through their medical plans and believe such coverage is out of reach, the rules may make it easier to provide limited support.

Fertility medications to be offered on TrumpRx

The administration has secured a third agreement with a pharmaceutical manufacturer to offer its products on TrumpRx, a new government-run website for direct-to-consumer prescription drug sales slated to go into operation next year. The company, EMD Serono, manufactures a fertility medication, GONAL-F, that is commonly used as part of In Vitro Fertilization treatments. The total cost for a single cycle of IVF ranges from $12,000 to $25,000, and fertility drugs such as GONAL-F typically account for nearly 20% of that cost. According to the announcement, the discounts offered by EMD Serono would likely result in savings over the current pricing available to individuals purchasing the medication without insurance.

The Centers for Medicare and Medicaid Services estimate that the agreement with EMD Serono will provide an individual with savings of up to $2,200 per IVF cycle on fertility drugs.

Standalone fertility benefit options for employers

Over the past five years, there has been marked growth in IVF coverage in employer-sponsored plans, as employers have responded to employee needs and expectations and the availability of new solutions in the market that can improve outcomes and help manage cost. In addition, 15 states currently require IVF coverage for insured plans, although those mandates vary in terms of eligibility and clinical coverage. Still, IVF coverage is far from universal and varies significantly based on employer size. According to Mercer’s National Survey of Employer Sponsored Health Plans, 47% of large employers (500 or more employees) cover IVF treatment, most often with a benefit limitation such as a lifetime maximum dollar amount (the median maximum is $25,000) or a limit on the number of covered cycles (the median limit is 3 cycles). Among smaller employers (50-499 employees), just 23% cover IVF.

Employers already have options to offer fertility benefits outside of their medical plans. These were revisited in new FAQs explaining how existing “excepted benefit” rules might be used specifically to provide a standalone fertility benefit. We review those options at the end of this post. However, currently, in our experience, fertility treatment coverage is rarely offered as an excepted benefit because the benefits are too limited to be of much help.

The new rules promised in the White House announcement could offer enough design flexibility to make this approach more attractive. While the rules still need to go through a review and comment period, they will apparently allow fertility benefits to be offered on a standalone self-funded basis as limited benefits like vision or dental benefits. The regulators are also considering modifications to the existing excepted benefit standards for supplemental health insurance, which are separately issued policies designed to fill gaps in primary medical coverage that meet specific regulatory criteria.

What this means for employers

To be clear, the FAQs do not mandate that employers provide any fertility coverage. As mentioned above, large employers have been steadily adding coverage to their medical plans, a trend that seems likely to continue. For employers that have not historically covered fertility benefits, the new rules may provide options to explore in addition to currently available fertility solutions. We recently blogged about some important considerations when designing an IVF benefit.

Employers should also keep an eye out for new policies and coverage pathways and watch for innovation in the pharmacy industry and across specialty reproductive health vendors driven by expedited drug approvals, increased competition in drug pricing, and the administration’s focus on encouraging fertility coverage. As more details emerge, it may make sense for some employers to explore designs that could incorporate TrumpRx or other DTC prices on fertility medication.

FAQs clarify current rules for providing standalone fertility benefits

Currently, standalone fertility benefits can be offered as “excepted benefits” – excepted from otherwise applicable laws such as ERISA and ACA benefit mandates – if the benefits satisfy existing rules for one of the following excepted benefit categories:

• A specified disease or illness policy can cover employees regardless of whether they are covered under the employer’s comprehensive group health plan but can’t be self-funded or coordinate with the benefits or exclusions in other group health plans offered.
• Group hospital or other fixed indemnity insurance must satisfy the same criteria as a specified disease or illness policy, plus pay a fixed dollar amount per period of hospitalization or illness related to infertility (for example, $100/day), regardless of the amount of expenses incurred.
• An employee assistance program may offer coaching and navigator services to help individuals understand their fertility options but can’t offer significant benefits for medical care.
• An Excepted Benefit Health Reimbursement Arrangement may reimburse certain out-of-pocket fertility expenses. Participants in an EBHRA must be offered, but do not need to be enrolled in, a traditional group health plan that would likely cover medical expenses such as prenatal care and labor/delivery. Given that the employer contribution to an EBHRA is capped at $2,200 for plan years beginning in 2026, employers might prefer to offer an HRA integrated with their medical coverage with flexibility to create their own dollar cap. However, employees in an integrated HRA must participate in a traditional group health plan.