Selection criteria, procedures and services
For an adult person over 21 years of age whose benefit certificate covers GRS, the individual if considered for surgery, must meet ALL of the following criteria:
1. Reached at least 21 years of age, and
2. Insured must have the ability to make a fully informed decision and give consent for treatment, and
3. Have been diagnosed with persistent gender dysphoria well documented,
4. Lived continuously for at least 6 months in the gender role (real-life experiences) that is consistent with the preferred gender, without periods of time to return to the original sex of the person, and
5. Completed at least 12 months of continuous hormonal of any male to female (MTF) or female to male (FTM)* and
6. Subjected to a urological examination to identify and treat genitourinary anomalies**, and
7. One referral from a qualified mental health professional is needed for breast/chest surgery. Two referrals from qualified mental health professionals who have independently assessed the patient are needed for genital surgeries. If the first referral is from the patient’s psychotherapist, the second referral may be from a person who has only had an evaluative role with the patient, whether mental health professional or primary care provider. Two separate letters, or one letter signed by both may be sent..
*Note: A trial of hormone therapy is not required to qualify for a mastectomy.
**Note: Only recommended for genitourinary surgeries
The following GRS services are considered for payment for a person who has met the selection criteria mentioned above:
Male to female
• Investment of penile skin
• Repair of the introit
• Vaginoplasty with vaginal construction with graft, and/or vulvoplasty
• Total breast reconstruction
• Voice modification (surgery or therapy)
• Elimination of hair on thorax
Female to male
• The placement (and removal if necessary) of an implantable erectile prosthesis
• The placement of testicular prostheses
• Subcutaneous mastectomy
• Vaginectomy, also known as colpectomy
• Testicular expanders
The services of continuous hormone replacement therapy may be included in the specific components of coverage allowed for some benefit plans. Therefore, CAREFULLY REVIEW insured benefit plan, summary plan description or contract for GRS provisions. If there is a discrepancy between a medical policy and affiliate benefit plan, the summary plan description or contract, the benefit plan, the summary plan description or contract will govern. The continuous hormone replacement therapy may include the following services:
1. Injections of the hormone by the medical service provider, such as during an office visit and / or infections of the self-administered hormone
2. Oral and injectable hormones obtained from a pharmacy.
3. Laboratory tests to monitor continuous hormonal therapy for people who are planning to undergo or have undergone GRS.
Hormonal regimens in transsexual adult persons
MTF transsexual person*
Oral: estradiol (47ß-estradiol valerate)
2 to 6 mg/day
Transdermal: estradiol patch
0.1 to 0.4 mg per 24 hours, changed once or twice weekly, dependieng on specific preparation type
5 to 20 mg IM every two weeks
Abuse potential; due to prolonged time to onset of effect and steady-state, greater risk of accumulation and overdose.
2 to 10 mg IM every week
100 to 400 mg/day oral
Monitor blood pressure and electrolytes.
50 to 100 mg/day oral
Possible add-on to slow male patterns baldness
2.5 to 5 mg per day oral
Possible add-on to slow male patterns baldness.
3.75 to 7.5 mg IM depot monthly
Inhibits gonadotropin secretion
3.6 mg subcutaneous implant monthly
FTM transsexual persons
160 to 240 mg/day oral
Oral preparation is not available in United States due to rare reports of hepatocellular carcinoma with long term use. Short half-life requires multiple daily doses (up to four times daily).
Testosterone enanthate or cypionate
50 to 100 mg IM every week OR
Weekly injections produce less peak-trough variation in effect (eg, mood); injection site reaction may occur.
Testosterone undecanoate â§
Testosterone gel 1%
2.5 to 10 grams of gel per day (equivalent to 25 to 100 mg/day testosterone)
Less variation in serum testosterone levels than injectable preparations; gel formulations can result in interpersonal transfer if contact occurs before fully dried (rare).
2.5 to 7.5 mg/day transdermal
Transdermal patch may produce lower serum testosterone levels and more skin irritation compared with gels
The following procedures or services are considered cosmetic or not medically necessary and not considered for payment when used to improve the gender of a person who intends to undergo, or has undergone GRS, including but not limited to:
• Brow lift
• Cheek implants
• Nose or chin implants
• Collagen injections
• Facial reconstruction bone / sculpture / reduction, including shortening of the jaw
• Forehead or conturing
• Hair transplant
• Reducing lips or lip augmentation
• Liposuction or body conturing
• Reduction or shaving trachea, thyroid chondroplasty
• Elimination of redundant skin
• Skin rejuvenation
• Singing lessons
Gender specific additional services of preventive medicine for GRS persons who are planning to undergo or have undergone GRS:
• The breast cancer screening for FTM and who have not undergone a mastectomy;
• Screening for cervical cancer for FTM individuals who have not had a hysterectomy with or without salpingo-oophorectomy, or
• The prostate cancer screening for MTF persons who have chosen to keep their prostate.
NOTE: Psychotherapy services may be included in specific components of coverage allowed for some benefit plans. Therefore, CAREFULLY REVIEW the member’s benefit plan, summary plan description or contract for GRS provisions. If there is a discrepancy between a medical policy and affiliate benefit plan,, the summary plan description or contract, the benefit plan, the summary plan description or contract will govern.
Acquisition, cryopreservation / freezing, storage / banking, and melting of reproductive tissues, such as eggs, oocytes, embryos, semen and testicular tissue of persons who are planning to undergo or have undergone GRS, even if the individual has reproduced in the past, are not considered for payment.
Psychotherapy is not necessary for the GRS, except when the initial assessment of mental health professional recommends psychotherapy that specifies treatment goals, estimates of frequency and duration throughout the real life experience.