Benefits for the treatment of gender dysphoria limited to the following services:
- Psychotherapy for Gender Dysphoria and associated co-morbid psychiatric diagnoses;
- Cross-sex hormone therapy:
- Cross-sex hormone therapy administered by a medical provider (for example during an office visit);
- Cross-sex hormone therapy dispensed from a pharmacy;
- Puberty suppressing medication injected or implanted by a medical provider in a clinical setting;
- Laboratory testing to monitor the safety of continuous cross-sex hormone therapy;
- Voice modification therapy
- Surgery for the treatment for gender dysphoria, including the surgeries listed below:
- Bilateral mastectomy or breast reduction
- Clitoroplasty (creation of clitoris)
- Hair removal required for reconstructive surgery
- Hysterectomy (removal of uterus)
- Labiaplasty (creation of labia)
- Metoidioplasty (creation of penis, using clitoris)
- Orchiectomy (removal of testicles)
- Penectomy (removal of penis)
- Penile prosthesis
- Phalloplasty (creation of penis)
- Salpingo-oophorectomy (removal of fallopian tubes and ovaries)
- Scrotoplasty (creation of scrotum)
- Testicular prosthesis
- Tracheal shave/reduction
- Urethroplasty (reconstruction of urethra)
- Vaginectomy (removal of vagina)
- Vaginoplasty (creation of vagina)
- Voice modification surgery
- Vulvectomy (removal of vulva)
The covered member must provide documentation of the following for breast surgery:
- A written psychological assessment from at least one qualified behavioral health provider experienced in treating gender dysphoria. The assessment must document that the covered member meets all of the following criteria:
The covered member must provide documentation of the following for genital surgery:
- A written psychological assessment from at least two qualified behavioral health providers experienced in treating gender dysphoria, who have independently assessed the covered member. The assessment must document that the covered member meets all of the following criteria.
- Persistent, well-documented gender dysphoria.
- Capacity to make a fully informed decision and to consent for treatment.
- Must 18 years or older.
- If significant medical or mental health concerns are present, they must be reasonably well controlled.
- Complete at least 12 months of successful continuous full-time real-life experience in the desired gender.
- Complete 12 months of continuous cross-sex hormone therapy appropriate for the desired gender (unless medically contraindicated).
The treatment plan is based on identifiable external sources including the World Professional Association for Transgender Health (WPATH) standards, and/or evidence-based professional society guidance.
For out-of-network benefits, you must obtain prior authorization as soon as the possibility of surgery arises and within 24 hours before admission for an inpatient stay.
If you fail to obtain prior authorization as required, benefits will be subject to a $400 penalty.
Depending upon where the covered health service is provided, any applicable prior authorization requirements will be the same as those stated under each covered health service category in this section.