7.5.13 Gender Identity Disorder/Gender Dysphoria Services

To be eligible for coverage, all services must be Medically Necessary.

Coverage includes:

• Mental health
• Hormone therapy (including puberty suppression therapy for adolescents)
• Surgical procedures

The Plan covers expenses for gender reassignment under the following conditions:

• The procedure(s) must be performed by a qualified professional provider
• The professional provider must obtain prior authorization for the surgical procedure
• The treatment plan must meet medical necessity criteria
• Covered procedures include:
  • Breast/chest surgery for female-to-male (FtM)
  • Gonadectomy (hysterectomy/oophorectomy for FtM or orchiectomy for MtF)
  • Single stage or multiple stage reconstruction of the genitalia
• The following procedures are excluded, unless the medical necessity criteria are met:
  • Blepharoplasty
  • Hair removal for surgical reconstruction (i.e. genital hair removal)
  • Breast augmentation procedures
  • Voice therapy/voice modification
  • Removal of redundant skin (i.e. Panniculectomy)

The following services are not medically necessary for all medical conditions and are excluded from coverage by the Plan as part of gender identity disorder treatment:

• Rhinoplasty
• Face-lifting
• Lip enhancement
• Facial bone reduction
• Brow Lift
• Liposuction/abdominoplasty of the waist (body contouring)
• Reduction of thyroid chondroplasty
• Facial hair removal/hair transplantationVoice modification surgery (laryngoplasty or shortening of the vocal cords)
• Skin resurfacing used in feminization
• Chin implants/Cheek Implants
• Nose implants
• Lip reduction
• Collagen injections
• Reversal, revision, or removal of gender reassignment surgery
• Make up evaluation
• Legal expenses related to name change
• Travel and lodging expenses

(p. 37 -38)

When a Participating Provider determines that a recommended Service is medically appropriate for an individual and the individual satisfies the criteria for the Service or treatment, we will provide coverage for the recommended Service regardless of sex assigned at birth, gender identity, or gender of the individual otherwise recorded by us. p. 17 Gender Affirming Treatment defined on p. 3 - Medical treatment or surgical procedures, including hormone replacement therapy, necessary to change the physical attributes of one’s outward appearance to accord with the person’s actual gender identity.

5.10.16 Gender Dysphoria

Benefits are provided for the treatment of Gender Dysphoria. Covered Services include, but are not limited to, Mental Health, Prescription Drug, and surgical procedures. Coverage is provided at the applicable benefit level for the type of Covered Services received, as shown in your Benefit Summary. For example, surgical procedures are subject to your provider surgical benefit and applicable inpatient or outpatient facility benefit. Treatment of Gender Dysphoria is subject to Medical Necessity as set forth in our medical policy, and must be received from licensed providers and facilities. Prior Authorization may apply. Please see section 4.4 for a list of services requiring Prior Authorization. (p. 43-44)