- This policy pertains to Washington PEBB members only effective 1/1/17.
- OHP (Oregon Medicaid) see OHP Prioritized List, Guideline Note 127 for treatment of Gender Dysphoria.
- For all other groups, breast augmentation is not covered. See UR 65 Transgender Surgery UM Criteria for covered gender transition procedures.
Breast augmentation will require prior-authorization utilizing the following coverage criteria
- Diagnosis of gender dysphoria (male to female) AND
- Has received at least 1 year of hormone therapy (unless there are contraindications) AND ONE:
- No measurable cup size growth, defined as less than an A cup, in one or both breasts OR
- Asymmetry where one breast did not have a measurable cup size growth, defined as less than an A cup.
- Documentation from surgeon of current cup size and proposed changes as well as photo documentation.