Community Hospital North. Clearvista Dr.

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1 100% IVF Refund Program Community Hospital North Clearvista Dr. N Dr. David Carnovale and Dr. Jeffrey Boldt, along with everyone at Community Reproductive Endocrinology, are committed to providing you with the best possible medical care to help you build your family. As part of that commitment, Community Reproductive Endocrinology has developed the IVF 100% Refund Program as another option to help more couples have a child. While this option will be well suited for many couples, other treatment choices may be more appropriate in certain circumstances. Our philosophy is to carefully review and investigate the particular reasons a couple may be having difficulty getting pregnant, followed by the development of an individualized plan. That plan can only be created with the full participation and guidance of those we are assisting. We are your team of fertility experts. Community Reproductive Endocrinology (Located on the campus of Community Hospital North) 7250 Clearvista Drive, Suite 365 Indianapolis, IN For more information call (317) (317) fax Communityfertility.com Ranked among the nation s highest-performing health systems and most integrated health care networks, Community Health Network has more than 90 sites of care and nearly 500 integrated physicians throughout central Indiana. This includes Community Hospitals East, North and South in Indianapolis and Community Hospital Anderson; The Indiana Heart Hospital, part of Community Heart and Vascular; Indiana Surgery Centers; Community Physicians of Indiana; Community Home Health Services; MedCheck walk-in care centers and MedCheck Express convenience clinics; employer health services; nursing homes; and other health care facilities. Community Health Network is committed to getting you well and back to your life Community Health Network CSK Let us help you build your family Community Reproductive Endocrinology ecommunity.com

2 What is an IVF Refund Program? How does it work? IVF refund programs were developed in response to infertility patients looking for more certainty in their efforts to have a child. You pay a fixed fee for the program services. With human reproduction there are limits to fertility enhancing treatments, such that couples with a favorable prognosis undergoing IVF can expect about a 45% chance of having a live born child with one attempt. For those couples who are successful on their first attempt, doing a single cycle of IVF makes the most sense. Unfortunately, we cannot predict who will be in the 45% who deliver a child, and who will be in the unlucky 55% who do not. If you do not deliver a live born child at 24 weeks of gestation or later by the end of your plan participation, you will receive a 100% refund of the plan fees. Frequently asked questions: With an IVF refund program, couples participating in the plan are provided with more treatment chances to be successful. Additionally, couples who are not successful in delivering a live born child will be refunded the plan fees they paid. Q How many attempts at IVF can I go through? Not everyone will be eligible to participate in the IVF Refund Plan. It is important that anyone participating in the IVF Refund Plan have a full understanding of the pros and cons for their particular circumstances. Q What if my pregnancy goes beyond 24 weeks and I lose my baby before delivering? A You will receive a 100% refund of the plan fees if you have exhausted all three fresh and three frozen attempts. A The refund plan allows for up to three fresh and three frozen embryo transfer cycles. Q Are there any other costs to do IVF and frozen embryo cycles that are not included in the program fees? A Yes. Medications, preliminary testing, and anesthesia fees are not included. All other costs related to the IVF and frozen embryo cycles are included in the program fees. Q What if my eggs need to be fertilized with sperm injection or if my embryos need assisted hatching? Are those fees included? A Yes. All embryology fees including sperm injection (ICSI), assisted hatching, extended embryo culture and embryo freezing and thawing are included. Q What if I want to withdraw before completing the program? A You may withdraw from the program at any time. After you have withdrawn, you will receive a refund of the plan fees you have paid, minus any charges for services that were provided. Q What if I do not want to freeze my embryos? A One of the eligibility criteria is a willingness to have extra embryos from fresh cycles frozen for use in the program. Further details about this program are available at Communityfertility.com We also offer comprehensive financial counseling sessions if you need additional information.

3 Community Reproductive Endocrinology IVF Refund Program In an effort to improve the chances for more couples who are trying to have a child to be successful, Community Reproductive Endocrinology offers an IVF Refund Program, also referred to as the "Program". This Program was designed for patients who do not have insurance coverage for in-vitro fertilization. With this Program, eligible patients will receive up to three (3) fresh IVF cycles and three (3) frozen embryo transfers until they have a live born delivery. If you do not achieve a live born delivery after completing the program then 100% of the fees paid for covered services under the Program will be refunded to you. The American Society for Reproductive Medicine established guidelines by which IVF programs can ethically offer such programs. The IVF Refund Program at Community Reproductive Endocrinology follows these guidelines. The ASRM Ethics Committee released their original findings on Risk-Sharing or Refund Programs in Assisted Reproduction in 1998 and reaffirmed their guidelines in 2006 as follow; The Committee finds that the risk-sharing form of payment for IVF is an option that might ethically be offered to patients without health insurance coverage for IVF if certain conditions that protect the patient are met. These conditions are that the criterion of success is clearly specified, that patients are fully informed of the financial costs and advantages and disadvantages of such programs, that informed consent materials clearly inform patients of their chances of success if found eligible for the risksharing program, and that the program is not guaranteeing pregnancy and delivery. It should also be clear to patients that they will be paying a higher cost for IVF if they in fact succeed on the first or second cycle than if they had not chosen the risk-sharing program, and that, in any event, the costs of screening and drugs are not included. The IVF Refund Program at Community Reproductive Endocrinology is offered to patients without insurance coverage for IVF. In some cases, where patients have inadequate or incomplete insurance coverage they may be able to participate if they decide it is to their advantage not to use their limited insurance benefits. The criterion for success of the IVF Refund Program at Community Reproductive Endocrinology is delivering a live born child. If you do not deliver a live born child then you will receive a 100% refund of the fees paid for covered services under the IVF Refund Program. Details of what service are and are not covered are provided below.

4 The financial cost of an IVF Refund Program is greater than the cost of a single IVF cycle. Patients who get pregnant on their first or second IVF attempt they may end up paying more with an IVF Refund Program. Couples who are determined to be medically eligible for the IVF Refund Program will generally have a somewhat better chance of pregnancy than patients who are not eligible. The IVF Refund Program at Community Reproductive Endocrinology is not guaranteeing pregnancy and delivery. The Program is designed to enable couples who do not have a live birth to be refunded 100% of the fees paid for covered services under this Program. The Committee was especially concerned about the incentives that risk sharing programs create for providers to take actions that might harm patients in order to achieve success and avoid a refund. For risk-sharing programs to be ethical, it is imperative that patients be aware of this potential conflict of interest, and that risk sharing programs not overstimulate patients to obtain a large supply of eggs or transfer more embryos than is safe for the patient, fetus and prospective offspring. Patients should be fully informed of the risks of multifetal gestation for mother and fetus, and have ample time to discuss and consider them prior to egg retrieval. Community Reproductive Endocrinology has always fully informed patients undergoing IVF of their risk for multiple gestation based upon their chance of pregnancy and the number of embryos that were being considered for transfer. Additionally, prior to transfer a discussion on the increased risks to the mother, fetus and children born from a multiple gestation pregnancy always takes place. Community Reproductive Endocrinology follows the most recent guidelines for number of embryos to be transferred from the American Society of Reproductive Medicine.

5 An important consideration of any refund program is what is and is not included in the program. Included Services (or Eligible Services) are: Up to Three (3) Fresh IVF Cycles with Embryo Transfer Injection class Trial embryo transfer Baseline and follow up ultrasounds for monitoring during ovarian stimulation Hormonal blood testing during ovarian stimulation (estradiol, progesterone) Management of ovarian stimulation Ultrasound during egg retrieval Surgical egg retrieval Facility charges for operating room Egg identification at egg retrieval Sperm analysis and preparation on day of egg retrieval Egg insemination (conventional process) Intracytoplasmic Sperm Injection (ICSI) if needed Rescue ICSI if needed (for failed conventional fertilization) Post insemination evaluation of fertilization Daily evaluation and culture of embryos up to 7 days Assisted Hatching if needed Embryology lab preparation for embryo transfer Ultrasound during embryo transfer Embryo transfer All embryology and andrology supplies Cryopreservation (freezing of excess embryos) Storage of frozen embryos for one year Up to Three (3) Frozen Embryo Cycles Trial embryo transfer Baseline and follow up ultrasounds Hormonal blood testing during uterine preparation Management of medication dosing and timing of transfer Thawing and evaluation of embryo(s) Embryology lab preparation for embryo transfer Ultrasound during embryo transfer Embryo transfer All embryology and andrology supplies

6 Excluded Services and paid separately include but are not limited to: *Pre-IVF screening tests (AMH, basal FSH) Pre-conception labs and infectious disease screening (may not be covered by your insurance) Anesthesia ($500 per fresh cycle-paid separately to anesthesia provider) Medications -estimated at $1500-$3000 per each fresh IVF cycle -estimated at $800 per each frozen embryo transfer cycle Pregnancy testing and pregnancy monitoring (this may be covered under your insurance) *Physician Consultation and pre IVF ultrasounds *Uterine evaluation sonohysterogram (fluid ultrasound) Embryo/egg storage beyond the first year Frozen cycles with remaining embryos/eggs after a live born delivery Donor sperm or Donor egg costs Keep in mind that some of the tests and evaluations excluded from the IVF Refund Program are covered under many insurance plans. You should check with your insurance and our office for assistance in determining if some or all of these excluded services may be covered under your insurance. If we participate with your insurance carrier and the service is covered, we will accept their payment as payment in full for those services, less any deductible or co-payment that is required from you. In order to be eligible to participate in the IVF Refund Program, insurance cannot be used for the included or eligible services for your IVF and frozen embryo cycles. In order to expand the eligibility of this program to more patients Community Reproductive Endocrinology offers eligibility based upon general criteria and maternal age. This is because a woman s age is one of the most important predictors of success. General eligibility is based upon a woman s ovarian potential as determined by her basal FSH, AMH, antral follicle count and other factors such as weight, general health and the health of her pelvic organs. The health of the male partner is also considered, however if the couple is willing to have sperm injection done, usually issues related to poor semen can be overcome.

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