CONCEPT DOES NOT REQUIRE AN UP FRONT DEPOSIT (Except for Standard IVF/ICSI/FET where out of pocket costs must be paid in advance)

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1 Concept Fertility Centre Explanation of Fees and Request Forms (Effective 1st January 2015) INTRODUCTION All Assisted Reproductive Technology Services such as; Artificial Insemination (AI) In Vitro Fertilisation (IVF) Intra Cytoplasmic Sperm Injection (ICSI) Assisted Hatching Blastocyst Culture Frozen Embryo Transfer (FET) Timed Intercourse (TIC) Post Coital Test (PCT) are associated with some out-of-pocket expenses. Detailed below are the sources of these expenses and the approximate amounts involved. CONCEPT DOES NOT REQUIRE AN UP FRONT DEPOSIT (Except for Standard IVF/ICSI/FET where out of pocket costs must be paid in advance) Complex treatments such as these involve the services of many different health professionals. Concept Fertility Centre will bill you for the following services: Concept Fertility Centre (Outpatient Services) Concept Day Hospital (Inpatient Services) see below You will also receive separate bills from your; Gynaecologist Anaesthetist Please check with their rooms. Outpatient Services account (Concept Fertility Centre) The first will be the Rebate which you will need to recover from Medicare and forward to Concept Fertility Centre. The second is an out-of-pocket component to be paid to Concept. The Medicare Safety Net will cover 80% of these out of pocket costs after you have reached your threshold, up to a Safety Net cap. Please check this with Medicare as it varies between families. Inpatient Services account (Concept Day Hospital) If you are with an approved Health Insurance Fund (see page 7), Concept will bill the fund directly for In-Patient services. These include accommodation and theatre fees. If you are with a nonapproved Health Insurance Fund, an out of pocket cost will be incurred. All uninsured patients will be billed directly. (For Standard IVF/ICSI/FET there will be no out of pocket expenses if you have adequate Health Insurance cover with an approved fund.) The fees listed in the Schedule are presented as a guide only. YOU WILL BE REQUIRED TO DISCUSS YOUR FEE SCHEDULE WITH THE COORDINATOR BEFORE YOU COMMENCE TREATMENT V65 April 2015 Authorised by Bruce Bellinge Page 1 of 8

2 SAFETY NET (EMSN) The Medicare s Safety Net will reimburse all residents of Australia 80% of all costs up to an Extended Medicare Safety Net cap, incurred for Medical services provided, which includes all of Concept s IVF related costs once the threshold has been reached- depending on your circumstances. Please check with Medicare to determine your Safety Net Threshhold YOU NEED TO REGISTER WITH TO ACCESS THE SAFETY NET Medicare determines that the Treatment Cycle starts from the day superovulatory drugs (FSH) are commenced OR Day 1 of your bleeding (LMP date) for a period of 30 days (global fee). What this means to you is that any bloods or ultrasounds performed before or after this may result in extra accounts being sent to you. TAX DEDUCTIBILITY (NMETO) The Government has tightened the eligibility to claim a tax deduction for medical expenses. It is now means tested. The general ruling from the Australian Taxation Office is that a tax rebate may be available to certain taxpayers for net medical expenses incurred, if eligible. This rebate is deducted directly from any tax payable. You need to confirm this with your accountant or the Australian Taxation Office. V65 April 2015 Authorised by Bruce Bellinge Page 2 of 8

3 FEE FOR SERVICE Effective 1st January 2015 CONDITIONS 1) The fees outlined in the following schedule are presented as a guide only. It is your responsibility to check with your doctor, the hospital and the anaesthetist what your fees will be. These fees were determined on the 1st January 2015 and are subject to change without notice. All accounts are rendered at the completion of your treatment and payment is requested within 30 days. 2) The fees as presented assume that you have top cover with an approved Private Health Insurance Fund. It is your responsibility to check with your Fund to ascertain the level of rebate that will apply to you. When you book for admission into the Concept Day Hospital you will be provided with advice on your likely fees. 3) If you obtain extra embryos/oocytes and elect to have them frozen and stored there is a 10 year storage charge for this service. Fees will apply for storage beyond 10 years. 4) Frozen embryos/oocytes transferred from another centre in Western Australia will incur an importation fee. Transfer from an interstate centre will incur an importation fee of $500. An additional storage fee will be charged if the Embryos are not used within 3 months. 5) Extra medication/consumables will incur a cost. Please check with your Health Fund on your eligibility for a rebate on the medications/consumables used and also confirm with the Centre the likely costs of medications/consumables prescribed for you. 6) Medicare provides free FSH based stimulatory drugs, progesterone based drugs and HCG for IVF procedures for all Australian residents with Medicare cover up to the day of embryo replacement; the continuing of medications after this will incur a fee. Patients undergoing a Frozen Embryo replacement will be required to pay for these medications. 7) Donor sperm incurs a fee, plus a fee for the catheter. 8) Partners sperm storage (two samples) will be charged a freezing fee. Fees will apply for storage after 10 years. 9) Sperm transferred from another centre in Western Australia will incur an importation fee. Transfer from an interstate centre will incur an importation fee of $500. An additional storage fee will be charged if all the sperm is not used within 3 months. 10) An Oocyte Recipient Cycle applies to Recipients for whom the egg collection, donation, fertilisation and culture of embryos is undertaken. Recipients of donated oocytes may have to wait until the donor has been completely screened for health status before the embryos can be released. This will take approximately three (3) months. A fee will be charged to the recipient for an ownership transfer change (Coordination/pre-treatment fee related to the donation of oocytes; only applicable to unknown recipients). (*NOTE: The immediate transfer of fresh (not frozen) embryos is possible BUT in order to do this no guarantee of the health status of the donor can be determined. The success rates of fresh transfer may be higher and there is no fee for the storage of embryos. Please discuss this with your gynaecologist). V65 April 2015 Authorised by Bruce Bellinge Page 3 of 8

4 11) In an Oocyte Recipient Cycle, those costs incurred by the donor, surplus to (10) above, are also the responsibility of the recipient, for example Doctors and Anaesthetist fees. 12) If you undergo donor insemination or artificial insemination, you will receive an account for this service. Medicare and the Safety Net will reimburse some of these costs to you. 13) If you attend any other doctor or diagnostic laboratory apart from your treating Gynaecologist, during your treatment cycle who then bills Medicare, this amount will not be paid to Concept by Medicare and you therefore will be liable for this amount. 14) Prior to commencing a Pre-implantation Genetic Diagnosis (PGD) cycle, a suitable, accurate, diagnostic test needs to be performed (feasibility studies), for which you will be charged. This is only required for the first PGD cycle a couple undertakes. It is possible that an accurate diagnostic test will not be able to be developed for a particular genetic disorder in which case PGD would not be possible. This will still incur the feasibility study fee. (PLEASE DISCUSS WITH THE SCIENTIFIC DIRECTOR) 15) For PGD cycles the testing laboratory will charge a fee for a cancelled PGD cycle. 16) Ovarian tissue freezing will be charged a fee for 10 year storage. Fees will apply for storage after 10 years. 17) Epididymal Sperm Aspiration procedures have a theatre charge and bed charge which are fully rebatable if you are with an approved Health Insurance Fund, with IVF inclusions. 18) Recipients of donated embryos will be charged an embryo storage fee of 10 years. Fees will apply for storage after 10 years. 19) Patients who use the services of a Counsellor will be charged a fee per session. Please check with reception at the time of booking. Exclusions apply. 20) Patients who have a cancelled IVF/ICSI cycle will be charged a fee. 21) Patients undergoing Timed Intercourse (TIC) on injections will be charged a management fee in addition to the blood tests and ultrasounds. 22) Patients undergoing Timed Intercourse, Post Coital Test (PCT), IVF, FET, AIH, DI, Tracking and Luteal Phase Tracking (LPT) may receive extra accounts for blood tests and ultrasounds, including any screening blood tests if required. 23) Patients undergoing Post Coital Testing (PCT) will also be charged a fee for consumables. V65 April 2015 Authorised by Bruce Bellinge Page 4 of 8

5 TOTAL FEE FEE FOR SERVICE TAILORED IVF PROCEDURES EXPECTED SAFETY NET EXPECTED OUT OF POCKET COSTS Oocyte Collection For Initial IVF rebated procedures in a calendar year (Item 13200) $7995 $3032 $1675 $3285 Extras ICSI (Item 13251) $955 $355 $108 $492 Assisted Hatching $550 $0 $0 $550 Blastocyst Culture $925 $0 $0 $925 Embryo /oocyte freezing $725 $0 $0 $725 Oocyte Collection For Subsequent IVF rebated procedures in a calendar year (Item 13201) $7995 $2831 $2432 $2730 Oocyte Collection For Surrogacy $7995 $0 $0 $7795 Cancelled IVF Cycle Prior to Oocyte Collection (Item 13202) $640 $395 $64 $181 Failed Oocyte Collection $5665 $3032 $1675 $955 Failed Oocyte Fertilisation $6300 $3032 $1675 $1590 Semen Preparation $155 $0 $0 $155 TAILORED FROZEN EMBRYO TRANSFER FET (Item 13218) $2910 $715 $702 $1491 Extras Assisted Hatching $550 $0 $0 $550 Blastocyst Culture $925 $0 $0 $925 PRE-GENETICS PGS $4510 $0 $0 $4510 PGD $4510 $0 $0 $4510 PGD (Translocation) $5050 $0 $0 $5050 Feasibility Studies $2860 $0 $0 $2860 Cancelled PGD Cycle (External Testing Laboratory) $600 $0 $0 $600 FROZEN OOCYTE TRANSFER FOT (Item 13218) $2910 $715 $702 $1491 Extras ICSI $955 $355 $108 $492 Assisted Hatching $550 $0 $0 $550 Blastocyst Culture $925 $0 $0 $925 V65 April 2015 Authorised by Bruce Bellinge Page 5 of 8

6 Healthfund Insurance- Day Surgery Fees apply if no Health fund insurance or inadequate cover (see page 8) for approved funds. TOTAL FEE HEALTHFUND INSURANCE EXPECTED SAFETY NET EXPECTED OUT OF POCKET COSTS Oocyte Collection** $960 $0 $0 $960 Embryo Replacement** $730 $0 $0 $730 Epididymal Aspiration $960 $0 $0 $960 STANDARD IVF PROCEDURES Oocyte Collection For Initial IVF/ICSI rebated procedures in a $5911 $3032 $1675 $1200 calendar year (Item 13200) ICSI (Item 13251) $463 $355 $108 $0 Embryo/oocyte freezing $725 $0 $0 $725 Oocyte Collection For Subsequent IVF/ICSI rebated procedures in a $6466 $2831 $2432 $1200 calendar year (Item 13201) Cancelled IVF Cycle Prior to Oocyte Collection (Item 13202) $395 $395 $0 $0 Failed Oocyte Collection $3035 $3032 $0 0 Failed Oocyte Fertilisation- Initial rebated procedures in a calendar $5461 $3032 $1675 $750 year Failed Oocyte Fertilisation- Subsequent rebated procedures in a $6016 $2831 $2432 $750 calendar year Healthfund Gap** $250 $0 $0 $250 Oocyte Retrieval ** (13212) $960 $0 $0 $960 Embryo Replacement** $730 $0 $0 $730 STANDARD FROZEN EMBRYO TRANSFER (NATURAL) FET (Item 13218) $2420 $715 $702 $1000 Healthfund Gap** $100 $0 $0 $100 Embryo Replacement** $730 $0 $0 $730 PGSꜝ and Blastocyst Cultureꜝ ** Only applies if there is no Healthfund cover ꜝ Only available for Frozen Embryo Cycles $4510 $925 $0 $0 $5435 ARTIFICIAL INSEMINATION PROCEDURES AI (Item 13203) $720 $413 $108 $199 Semen Preparation (Item 13221) $155 $43 $21 $91 Counselling session (AI) $190 $0 $0 $190 Cancelled DI/AIH (Item 13203) $550 $413 $108 $29 Donor Sperm $400 $0 $0 $400 Catheter $160 $0 $0 $160 V65 April 2015 Authorised by Bruce Bellinge Page 6 of 8

7 FEE FOR SERVICE CONTINUED TOTAL FEE SAFETY NET EXPECTED OUT OF POCKET COSTS OOCYTE RECIPIENTS EITHER (1) Known Recipient For Immediate IVF-ET (Embryology only) $2170 $0 $0 $2170 OR (2) Unknown Recipient Patient Management At Time Of Oocyte Donation $2170 $0 $0 $2170 Frozen Embryo Transfer $2910 $715 $702 $1491 AND Transfer Fee $600 $0 $0 $600 Embryo Freezing $725 $0 $0 $725 SURROGACY In addition to IVF costs Patient Management $2750 $0 $0 $2750 Subsequent Surrogacy Cycle $550 $0 $0 $550 Oocyte Collection and ET $7995* $0 $0 $7995 Counselling $190 per hr $0 $0 $190 per hr **Plus extras (e.g. ICSI, Blastocyst, Assisted Hatching, Embryo Freezing) ADDITIONAL SERVICES Sperm Freezing/Storage $600 $0 $0 $600 Sperm/Embryo Importation From $200 $0 $0 From $200 Imported Sperm/Embryo Storage $290 $0 $0 $290 Counselling $190 per hr $0 $0 $190 per hr Medications From $160 $0 $0 From $160 Timed Intercourse (injections) $300 $0 $0 $300 Post Coital Test (consumables) $160 $0 $0 $160 V65 April 2015 Authorised by Bruce Bellinge Page 7 of 8

8 APPROVED HEALTH INSURANCE FUNDS If you have the Approved level of cover for Hospital then the following Health Insurance Funds will pay, subject to any excesses or co-payments as per your Health Fund agreement: ACA Health Benefits Fund AMA Australian Health Management Australian Unity Health CBHS Health Fund CUA Health Defence Health Garrisons GMF Health/ Healthguard Health Benefits GMHBA Goldfields (GMF) Government Employees Grand United Corporate Health HBF Health Care Insurance Health Partners HCF HIF Manchester Unity Medibank Private Navy Health Onemedifund Peoplecare Phoenix Health Fund Police Health Queensland Country Health Railway and Transport Health Fund Reserve Bank Health RT Health Fund Teachers Federation Health Teachers Union Health Transport Health United Ancient Order of Druids Westfund NON APPROVED HEALTH INSURANCE FUNDS The following Health Insurance Funds will pay for approximately 75% of your fees. NIB St Luke s Health Cessnock District Health Fund La Trobe Health MBF BUPA Mildura District Hospital Fund IT IS YOUR RESPONSIBILITY TO ASCERTAIN THE ACTUAL FEES CHARGED, AND THE LEVEL OF YOUR PRIVATE HEALTH FUND WILL PROVIDE FOR YOU. Item numbers to quote them are; Oocyte retrieval Embryo Transfer V65 April 2015 Authorised by Bruce Bellinge Page 8 of 8

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