Value Option Plan

Gender Affirming Care

This plan recognizes that gender diverse members require health care delivered by healthcare providers experienced in gender affirming health. This page will help members navigate our gender affirmation surgical benefits.

Gender affirmation surgical benefits are limited to the following:

• For female to male surgery: mastectomy, hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty, phalloplasty, urethroplasty, and placement of an erectile prosthesis 
• For male to female surgery: penectomy, orchiectomy, vaginoplasty, clitoroplasty, labiaplasty, and initial breast augmentation 

Note: Your provider must submit a treatment plan including all surgeries planned and the estimated date each will be performed. A new prior approval must be obtained if the treatment plan is approved and your provider later modifies the plan.

Note: Benefits for gender affirmation surgery are limited to once per covered procedure, per lifetime. Benefits are not available for repeat or revision procedures when benefits were provided for the initial procedure. Benefits are not available for gender affirmation surgery for any condition other than gender dysphoria.

Note: We only cover procedures outlined in Table 1 of Cigna's Medical Coverage Policy for Gender Dysphoria Treatment.

Gender affirmation surgery on an inpatient or outpatient basis is subject to the pre-surgical requirements listed below. The patient must meet all requirements. 

• Prior approval is obtained (Call Cigna at 877-220-NALC (6252) for prior approval)

• Patient must be at least 18 years of age at the time prior approval is requested and the treatment plan is submitted

• Diagnosis of gender dysphoria by a qualified healthcare professional 
• Patient’s gender dysphoria is not a symptom of another mental disorder 
• Gender dysphoria causes clinical distress or impairment in social, occupational, or other important areas of functioning 

• Patient must meet the following criteria: 
• Documentation the individual has lived for at least 12 continuous months in a gender role that is congruent with their gender identity (including place of employment, family, social and community activities) 
• 12 months of continuous hormone therapy appropriate to the patient’s gender identity
• One referral letter of support from a qualified mental health professional for mastectomy or initial breast augmentation
• Two referral letters of support from qualified mental health professionals for all other gender affirmation procedures 
• If medical or mental health concerns are present, they are being optimally managed and are reasonably well-controlled 

• Reversal of a gender affirmation surgery is covered only when determined to be medically necessary or a complication occurs.