Transgender and Non-binary Care

This guide describes the benefits available to support transgender and gender non-binary community members and their unique needs, such as gender dysphoria. It explains how to access doctors, hospitals, and other services. In addition to preventive and primary medical care, your plan covers behavioral health services, medication, hormone therapy, and surgery.

Gender dysphoria refers to discomfort or distress caused by a discrepancy between a person's gender identity and that person's sex assigned at birth.^1
1 World Professional Association for Transgender Health (WPATH). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th version. Accessed May 2022.

Support Team

Stanford Health Care Alliance Member Care Services is here to support you with any benefit questions, guidance on appropriate resources, or need help coordinating your care. 

• Mon - Fri, 6:30 am - 7 pm
• (855) 345-7422

Stanford Health Care has a stand-alone clinic dedicated to the care and concerns of LGBTQ+ patients. To learn more, visit the LGBTQ+ Health Program page.

What's Covered

Behavioral Health

The decision to begin care can be complicated and emotional. It can impact your relationships with family and friends. Your medical plan includes personalized behavioral health services to support you on this journey.

Finding Providers

• Go to the directory
• Enter the zip code of where you'd like to begin the search for a provider, then click Search
• When you see the list of purple tabs, click on Mental Health
• Click Mental Health Professionals
• Scroll down to Gender Identity and click
• From here, you will see a list of providers
• You must call the provider of choice to make an appointment.
  • It is important to remember that mental health professionals often do not have receptionists who can take your call. Most handle all administrative tasks themselves and will usually be in session when you call. Please leave your contact info so they can contact you when available.
  • You may get discouraged by the response time, so choose a few providers you might want to work with and contact each of them.

Additional Options

Teladoc
Teladoc offers virtual therapy visits by phone or video chat. Visit our Teladoc page or call (855)835-2362. You can also download the Teladoc app to get started.

Resources for Living
Your Postdoc Assistance Program, administered by Resources for Living, offers 10 free, confidential counseling sessions per year for each issue you're concerned about. Call 888-238-6232 to get started.

Physical Health

Your health plan provides comprehensive coverage for medication, hormone therapies, surgeries, behavioral health, and other services to help meet the needs of people who are transgender or gender non-binary. As with some other covered services, certain clinical requirements must be met for benefits to apply. To confirm these requirements are met, some services require precertification. The following sections provide more details.

Medication and Hormone Therapy

When medical necessity has been confirmed, medication and hormone therapy are covered under your plan, including puberty suppression prescription medications for children and adolescents. It's important to talk to your healthcare provider before taking hormones to understand the side effects and what to watch for while taking them. Your doctor may order lab tests to monitor your hormone levels. Testosterone or estrogen therapies require your doctor to submit a precertification (prior authorization) request and are usually covered under your pharmacy benefit. To learn how other medications used for gender-affirming care are covered, click the links below.

• Progestins include drugs covered under the pharmacy and medical plans. Those covered under the pharmacy plan that may be used for transgender services, such as Depo-Provera®, do not require precertification. Those covered under the medical plan are subject to Aetna® medical criteria.
• Gonadotropin-releasing hormone analogs and antagonists include some non-self-injectable drugs, such as Lupron® and Supprelin® LA, which are covered under the medical plan and subject to Aetna® medical criteria.

Gender-affirming surgeries, reconstructive services, and facial and body contouring

Surgical transition is also referred to as gender-affirming surgery or gender-confirming surgery. Your medical plan includes coverage for transgender and gender-diverse surgical procedures. These include reconstructive services and facial and body contouring.

Precertification to confirm medical necessity is required. Examples include:

• Breast removal (transgender mastectomy) or breast augmentation/lift (breast implants)
• Bottom surgery, including removal of reproductive organs and creation of exterior sexual organs
• Facial/body contouring to match your gender identity better

Precertification

Precertification confirms details of your health coverage and whether certain clinical criteria have been met before you receive services. In-network providers are generally responsible for obtaining precertification for you.

Out-of-network providers are not responsible for obtaining precertification. Check your plan documents to see if your plan includes coverage for out-of-network care. If it does and you want to use an out-of-network provider, you are responsible for getting precertification to determine if a service will be covered.

Below are services that typically require precertification:
Top Surgery

• Breast augmentation
• Breast removal (transgender mastectomy)

Bottom surgery

• Genital reconstructive surgery
  • Clitoroplasty (making a clitoris)
  • Labiaplasty (making labia)
  • Metoidioplasty (making a phallus)
  • Penectomy (removing penis)
  • Phalloplasty (making a phallus)
  • Placement of a testicular prosthesis and erectile prosthesis
  • Scrotoplasty (making a scrotum)
  • Urethroplasty (making a urethra)
  • Vaginectomy (removing vagina)
  • Vaginoplasty (making a vagina)
• Gonadectomy
  • Hysterectomy (removing uterus)
  • Oophorectomy (removing ovaries)
  • Orchiectomy (removing testicles)

Reconstructive services and facial and body contouring

• Abdominoplasty
• Blepharoplasty
• Calf implants
• Chemical peel
• Dermabrasion
• Electrolysis and laser hair removal
• Facelift
• Facial/body contouring to match your gender identity better
• Facial bone reconstruction
• Facial bone reduction
• Genioplasty and chin augmentation
• Gluteal augmentation (implants/lipo-filling)
• Hair cranial prosthesis (wigs)
• Hair grafts
• Hair implants
• Hair regrowth drugs
• Hormone therapy and other prescription drugs
• Hospital stays
• Infraumbilical panniculectomy (excision of excessive skin and subcutaneous tissue in the abdomen)
• Laryngoplasty/vocal cord (voice) surgery
• Lipofilling (breast, body, face)
• Liposuction (contour modeling of the waist)
• Liposuction to reduce fat in hips, thighs, buttocks
• Male chest reconstruction
• Mastopexy
• Other professionals (such as voice coaches and bodily movement coaches)
• Partial hospitalization/day treatment
• Pectoral implants
• Permanent hair removal
• Rhinoplasty
• Subcutaneous injection of filling material
• Suction-assisted lipoplasty of the waist
• Tracheal shave
• Treatment reversal
• Voice and communication therapy
• Voice therapy and surgery

Precertification Requirements for Gender-affirming Surgery

Gender-affirming surgery is considered medically necessary if you meet the following requirements.

Top surgery

• A letter of referral
  • Aetna Choice® POS II plan: from a qualified behavioral health professional
  • SHCA plan: from your primary care provider (PCP)
• Persistent, well-documented gender dysphoria
• Capacity to make a fully informed decision and to consent to treatment
• For breast removal if you’re under 18 years old, completion of one year of testosterone treatment (not applicable for adults)
• For breast augmentation, completion of 6 months of feminizing hormone therapy as appropriate for your goals (unless hormone therapy is not desired or medically contradicted); 12 months for adolescents under age 18
• Confirmation that any significant medical or mental health concerns are reasonably well controlled

Bottom surgery

• One letter of referral from a qualified behavioral health professional
• Persistent, well-documented gender dysphoria
• Capacity to make a fully informed decision and to consent to treatment
• Confirmation that any significant medical or mental health concerns are reasonably well controlled
• 6 months of continuous hormone therapy as appropriate for your goals (unless hormone therapy is not desired or medically contradicted); 12 months for adolescents under age 18
• For genital reconstruction surgery, 12 months of living in a gender role appropriate for your gender identity (real-life experience)

You can review the complete list of Aetna® clinical criteria for coverage.

How to Request Precertification

• In-network: Your doctor will handle precertification for you
• Out-of-network: Your doctor may handle precertification for you. If not, you can call SHCA Member Care Services at 855-345-7422 for assistance

Turnaround Times

Once Aetna receives the precertification request and required information, the standard  processing time is 15 days. If information is missing, we’ll request the additional information within 15 days of receiving the request.

How Your Plan Pays