Gender reassignment surgeries/procedures listed in Tables I and II require prior authorization and are covered for transmen or transwomen when documentation submitted confirms that all of the following criteria are met:
- Member is 18 years of age or older
- Member has the capacity to make fully informed decisions including consent to treatment.
- Gender Dysphoria has been diagnosed by qualified health provider(s) and is a persistent diagnosis
- Member has successfully lived full-time in the desired gender role without retuning to the original gender for a minimum of 12 months.
- Face to face comprehensive evaluation and treatment plan by the provider administering hormonal therapy and by the *surgeon performing requested surgery.
- A behavioral health evaluation, supporting candidacy for gender-confirming surgery, performed within 6 months of the request for authorization for surgery.
- Attestation that the member is adhering to medical and behavioral health treatment as recommended and is medically and behaviorally stable.
- Attestation that the member has access to primary care provided by a clinician who is has an understanding of gender dysphoria and who can perform and coordinate follow up care including appropriate screenings and monitoring.
- The treatment plan must conform to WPATH standards and/or to other evidence-based, agreed upon, external guidelines.
- Surgeons must have demonstrated training, experience, and proficiency in performing the requested surgical procedure.
- Breast Augmentation mammaplasty requires documentation by the physician prescribing hormones and the surgeon that breast enlargement after undergoing hormone treatment for 12 months is not sufficient for comfort in the social role.
No authorization is required for behavioral and medical health.
Services for Members Less than 18 Years of Age:
- Pharmacological and hormonal therapy that is non-reversible and/or produces masculinization or feminization
- Pharmacological and hormonal therapy to delay physical changes of puberty