Fund an IVF cycle: coverage appeal, grants, and real clinic prices

  1. Request the Summary Plan Description or certificate of coverage
    30 min

    This step produces the document every appeal in this playbook hangs on: the Summary Plan Description (SPD) if your plan is governed by ERISA, or the Certificate of Coverage (CoC) if it is a fully insured state-regulated plan.

    Inside it you will find the covered-services list, every exclusion, and the plan’s own definition of medical necessity. Without it, every appeal rests on guesswork.

    Start this step first and let it run in the background. Federal law — ERISA § 104(b)(2) — gives plans 30 days to respond, but most deliver within 5–10 business days.

    Call your employer’s HR or benefits department and say: “I need a copy of the full Summary Plan Description for my health plan, including the schedule of benefits and the exclusions section. Please email it or tell me how to access it online.”

    On an individual or small-group policy, ask for the Certificate of Coverage instead.

    If HR cannot help, call the member-services number on the back of your insurance ID card, repeat the request, and write down the reference number they give you and the promised delivery method.

    Follow up in writing — email works — with your full name, member ID, group number, and a request for the “complete plan document including all exclusions and the definition of medical necessity.”

    If the plan portal offers a PDF download, save it immediately to a folder named IVF-PlanDocs before the session expires.

    Keep in IVF-PlanDocs: the SPD or CoC PDF, the date you requested it, the name and department of the person you spoke with, and any reference or case number. You will need all of it for the appeal letter in Phase 2.