Gender dysphoria
Benefits for the treatment of gender dysphoria provided by or under the direction of a physician.
For the purpose of this benefit, "gender dysphoria" is a disorder characterized by the specific diagnostic criteria classified in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association.
Benefits for the treatment of gender dysphoria limited to the following services:
- Psychotherapy for Gender Dysphoria and associated co-morbid psychiatric diagnoses;
- Continuous hormone therapy administered by a medical provider (for example during an office visit);
- Continuous hormone therapy dispensed from a pharmacy (covered as per pharmacy benefits);
- 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
- Breast augmentation with implants or fat transfer
- Clitoroplasty (creation of clitoris)
- Hysterectomy (removal of uterus)
- Labiaplasty (creation of labia)
- Laser or electrolysis hair removal in advance of genital reconstruction prescribed by a physician for the treatment of Gender Dysphoria
- Metoidioplasty (creation of penis, using clitoris)
- Nipple/areola reconstruction
- Orchiectomy (removal of testicles)
- Penectomy (removal of penis)
- Penile prosthesis
- Phalloplasty (creation of penis)
- Revision of a reconstructed breast
- Salpingo-oophorectomy (removal of fallopian tubes and ovaries)
- Scrotoplasty (creation of scrotum)
- Testicular prosthesis
- Tissue expander placements
- Tracheal shave/reduction
- Urethroplasty (reconstruction of urethra)
- Vaginectomy (removal of vagina)
- Vaginoplasty (creation of vagina)
- Voice modification surgery
- Vulvectomy (removal of vulva)
Surgical treatment for Gender Dysphoria may be indicated for individuals who provide the following documentation:
- For breast surgery (mastectomy, breast reduction or breast augmentation), a written clinical assessment from at least one Qualified Healthcare Professional experienced in treating Gender Dysphoria is required. The assessment must document that an individual 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 at least 18 years of age for breast augmentation
- Favorable psychosocial-behavioral evaluation to provide screening and identification of risk factors or potential postoperative challenges
- For breast augmentation, continued Gender Dysphoria following the completion of 12 months of continuous hormone therapy prior to the breast procedure is required
- For thyroid cartilage reduction and/or voice modification surgery (e.g., laryngoplasty, glottoplasty or shortening of the vocal cords), a written clinical assessment from at least one Qualified Healthcare Professional experienced in treating Gender Dysphoria is required. The assessment must document that an individual 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 at least 18 years of age
- Favorable psychosocial-behavioral evaluation to provide screening and identification of risk factors or potential postoperative challenges
- Completion of 6 months of continuous hormone therapy prior to surgery is required for voice masculinization
- For voice modification surgery, documentation of presurgical voice lessons and/or therapy
- For genital surgery, a written clinical assessment from at least two Qualified Healthcare Professional experienced in treating Gender Dysphoria, who have independently assessed the individual, is required. The assessment must document that an individual 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 at least 18 years of age
- Favorable psychosocial-behavioral evaluation to provide screening and identification of risk factors or potential postoperative challenges
- Complete at least 12 months of successful continuous full-time real-life involvement in the identified gender
- Complete 12 months of continuous hormone therapy appropriate for the experienced gender (unless medically contraindicated or not indicated for gender)
- Treatment plan that includes ongoing follow-up and care by a Qualified Healthcare Professional experienced in treating Gender Dysphoria
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.