Understanding your insurance: SPD, medical policy, formulary

Three documents you actually need

Summary Plan Description (SPD): the master document for self-funded employer plans. The full legal terms, including infertility exclusions and limits. HR can usually email it to you within a few days.

Medical policy / coverage policy for infertility: most insurers (Aetna, Cigna, BCBS, UHC) publish public clinical policy bulletins covering exactly which CPT codes they cover under what circumstances. Search '[insurer name] infertility medical policy.'

Pharmacy formulary: lists which fertility medications are covered, at what tier, with which prior authorizations. Available on your insurer's member portal under 'pharmacy benefits.'

How to read the SPD

Search the PDF for: 'infertility,' 'IVF,' 'in vitro,' 'assisted reproductive technology,' 'ART,' 'gamete,' 'oocyte,' and 'GIFT.' Note any lifetime maximums (often $10,000–$25,000 or 2–4 cycles), age caps, and the precise definition of 'infertility' the plan uses.

Get the answer in writing

Verbal quotes from the insurance member line are often wrong. Request a written 'pre-treatment estimate' or 'predetermination of benefits' for the specific CPT codes your clinic will bill. This is a written commitment from the insurer about what they will and won't cover at the contracted rate.