Gender Dysphoria
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;
  • Surgery for the treatment for gender dysphoria, including the surgeries listed below:
    • Male to Female:
      • Clitoroplasty (creation of clitoris)
      • Labiaplasty (creation of labia)
      • Orchiectomy (removal of testicles)
      • Penectomy (removal of penis)
      • Urethroplasty (reconstruction of female urethra)
      • Vaginoplasty (creation of vagina)
    • Female to Male:
      • Bilateral mastectomy or breast reduction
      • Hysterectomy (removal of uterus)
      • Metoidioplasty (creation of penis, using clitoris)
      • Penile prosthesis
      • Phalloplasty (creation of penis)
      • Salpingo-oophorectomy (removal of fallopian tubes and ovaries)
      • Scrotoplasty (creation of scrotum)
      • Testicular prosthesis
      • Urethroplasty (reconstruction of male urethra)
      • Vaginectomy (removal of vagina)
      • Vulvectomy (removal of vulva)]
Genital surgery and bilateral mastectomy or breast reduction surgery documentation requirements:
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:
    • Persistent, well-documented gender dysphoria.
    • Capacity to make a fully informed decision and to consent for treatment.
    • Must be 18 years or older.
    • If significant medical or mental health concerns are present, they must be reasonably well controlled.
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.
Prior Authorization Requirement for Surgical Treatment
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.
Prior Authorization Requirement for Non-Surgical Treatment
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.