Gender Dysphoria and/or Gender Reassignment Services: Certain procedures associated with gender dysphoria treatment and/or gender reassignment surgery are considered non-medically necessary, such as:

• No more than one gender reassignment surgery in the individual’s lifetime while covered under the PEBP CDHP Plan or any previous self-funded PPO Plan.
• Certain procedures are considered cosmetic, such as (this is not an all-inclusive list):
  • Blepharoplasty o Hair transplants, wigs, and hair growth products o Breast augmentation/augmentation mammoplasty, except when the gender reassignment patient has received 12 continuous months of hormonal (estrogen) therapy and the breast tissue growth failed to result a Tanner Stage 5 on the puberty scale, as determined by the provider, or the recipient has a medical contraindication to hormone therapy. The Plan Administrator will determine authorization and consent to care based on medical necessity.
  • Rhinoplasty Electrolysis (hair removal) Laser hair removal Facial reconstruction including facial feminization surgery to include but not be limited to facial bone reduction, face lift and certain facial plastic reconstruction. (The UM company to determine if a procedure is cosmetic and the Plan Administrator has discretionary authority to determine coverage.
• Other Exclusions include (this is not an all-inclusive list):
  • Sperm preservation in advance of hormone treatment or gender surgery
  • Cryopreservation of fertilized embryos
  • Voice modification surgery
  • Voice therapy
  • Drugs for sexual performance or cosmetic purposes (except for hormone therapy as described in this document)
  • Transportation, meals, lodging or other similar expenses associated with gender dysphoria services
  • One (1) gender dysphoria reassignment surgery per lifetime while covered under any current or previous PEBP self-funded health plan.

The UM company has full authority to determine if a procedure or service is not medically necessary. (p. 92-93 CDHP Plan).

"This Plan excludes expenses related to cosmetic procedures performed as a component of a gender reassignment, including, but not limited to the following services:

• Abdominoplasty
• Blepharoplasty
• Breast augmentation*
• Brow lift
• Calf implants
• Cheek/malar implants
• Chin/nose implants
• Collagen injections
• Construction of a clitoral hood
• Drugs for hair loss or growth
• Face-lifting
• Facial bone reduction
• Forehead lift
• Hair removal
• Hair transplantation
• Lip enhancement or reduction
• Mastopexy
• Neck tightening
• Pectoral implants
• Reduction thyroid chondroplasty
• Removal of redundant skin
• Rhinoplasty
• Skin resurfacing
• Voice modification surgery (laryngoplasty or shortening of the vocal cords)
• Voice therapy/voice lessons

*Breast augmentation/augmentation mammoplasty excluded, except when the gender reassignment patient has received 12 continuous months of hormonal (estrogen) therapy and the breast tissue growth failed to result a Tanner Stage 5 on the puberty scale, as determined by the provider, or the recipient has a medical contraindication to hormone therapy. The Plan Administrator will determine authorization and consent to care based on medical necessity." (p. 88 Premier Plan)

"Services received in connection with Gender Dysphoria, which includes the following:

• Abdominoplasty;
• Blepharoplasty;
• Body contouring, such as lipoplasty;
• Breast enlargement, including augmentation mammoplasty and breast implants;
• Brow lift;
• Calf implants;
• Cheek, chin, and nose implants;
• Cryopreservation of fertilized embryos;
• Drugs for hair loss or growth;
• Face lift, forehead lift, or neck tightening;
• Facial bone remodeling for facial feminizations;
• Hair removal;
• Hair transplantation;
• Injection of fillers or neurotoxins;
• Lip augmentation;
• Lip reduction;
• Liposuction;
• Mastopexy;
• Pectoral implants for chest masculinization;
• Reversal of genital surgery or reversal of surgery to revise secondary sex characteristics;
• Rhinoplasty;
• Skin resurfacing;
• Sperm preservation in advance of hormone treatment or gender surgery;
• Surgical or hormone treatment on Members under eighteen (18) years of age;
• Surgical treatment not Prior Authorized by HPN;
• Thyroid cartilage reduction; reduction thyroid chondroplasty; trachea shave (removal or reduction of the Adam’s Apple);
• Transportation, meals, lodging or other similar expenses;
• Voice lessons and voice therapy; and
• Voice modification surgery." (p. 30 Health Plan of Nevada)