Back to Trans Health Issues Page
Below is information from some UC employeer health providers. UCLGBTIA does NOT recommend one provider over another. Please refer to the UC Benefits web resources for more information on all health care providers.
Please note: Health Net and PacifiCare are merging into Health Net alone.
Blue Cross PLUS Plan for Active Members
- January 1, 2007
- http://www.bluecrossca.com/member/uc/plansbenefits/yourbenefits/evidenceofcoverage/pw_a088923.pdf
Transgender Surgery
Benefits - Co-Payments
See pages 28-29.
Transgender Surgery
Benefits
- Conditions for Coverage
- Transgender Surgery Co-Payments and Maximums
- Transgender Surgery Care That Is Covered
- Transgender Surgery Care That Is Not Covered
See pages 55-56.
Blue Cross PPO Plan in California Without Medicare
- January 1, 2007
- http://www.bluecrossca.com/member/uc/plansbenefits/yourbenefits/evidenceofcoverage/pw_a088928.pdf
Transgender Surgery
Benefits
- Calendar Year Deductibles
- Co-Payments
- Maximums
See pages 23-24.
Transgender Surgery
Benefits
- Conditions for Coverage
- Transgender Surgery Deductibles, Co-Payments, and Maximums
- Transgender Surgery Care That Is Covered
- Transgender Surgery Care That Is Not Covered
See pages 45-46.
Kaiser Permanente
Traditional Plan Disclosure Form and Evidence of Coverage for the University
of California
- Effective January 1, 2007
- http://my.kp.org/ca/universityofcalifornia/benefits_ca_traditionalHMOPlan.html
- Member Service Call Center: 1-800-464-4000 (TTY 1-800-777-1370), weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
[Below from p. 6]
Lifetime Maximum
Services covered under "Transgender Services" in the "Benefits
and Cost Sharing" section $75,000
[Below from p. 18]
Getting a Referral
Medical Group authorization procedure for certain referrals
Transgender surgery. If your treating Plan Provider makes a written referral
for transgender surgical Services (genital surgery or mastectomy), the
Medical Group's Transgender Surgery Review Board will authorize the Services
if it determines that the Services meet the requirements described in
the Medical Group's transgender surgery guidelines, which are available
upon request
[Below from p. 41]
Benefits and Cost
Sharing
Transgender Services
Up to a $75,000 lifetime maximum, we cover genital surgery and mastectomy
if Medical Group authorizes the surgery in accord with "Medical Group
authorization procedure for certain referrals" under "Getting
a Referral" in the "How to Obtain Services" section. The
lifetime maximum is calculated by adding up the Charges for transgender
surgical Services we cover for you, including any related travel and lodging
preauthorized in accord with our travel and lodging guidelines, less any
Cost Sharing that you paid for those Services.
You pay the following for these covered transgender surgical Services:
• Office visits: a $15 Copayment per visit
• Outpatient surgery and other outpatient procedures: a $15 Copayment
per procedure
• Hospital inpatient care (including room and board, drugs, and
Plan Physician Services): a $250 Copayment per admission
Note: The following Services are not covered under this "Transgender
Surgery" section:
• Outpatient prescription drugs (instead, refer to "Outpatient
Prescription Drugs, Supplies, and Supplements" in this "Benefits
and Cost Sharing" section)
• Outpatient administered drugs (instead, refer to "Outpatient
Care" in this "Benefits and Cost Sharing" section)
• Psychological counseling (instead refer to "Mental Health
Services" in this "Benefits and Cost Sharing" section)
• Outpatient laboratory and imaging Services (instead, refer to
"Outpatient Imaging, Laboratory, and Special Procedures" in
this "Benefits and Cost Sharing" section)
Transgender Services exclusion
• Surgery or other Services that are intended primarily to change
or maintain your appearance, voice, or other characteristics, except for
the covered transgender services listed above.
Health Net
of California
SUMMARY OF BENEFITS AND DISCLOSURE FORM
- 1/1/2007
- https://www.healthnet.com/static/custom/unprotected/pdfs/sb_df_uc.pdf
- Health Net Member Services Department1-800-522-0088
[Below from p. 5]
Schedule of benefits
and coverage
Type of service & what you pay for services (medical benefits)1
Professional services
Transgender surgery and services Covered in full
[Below from p. 10]
Endnotes
16 Transgender surgery and related services, including travel and lodging
costs, require prior authorization. Transgender surgery and related services,
including travel and lodging costs, that are authorized by the Plan, are
subject to a combined Inpatient and Outpatient lifetime benefit maximum
of $75,000 for each Member.
PacifiCare
University of California 2006 Combined Evidence of Coverage and Disclosure
Form
- http://www.pacificare.com/vgn/images/portal/cit_60701/600625845_UC06_EOC.pdf
- Questions? Call the [PacifiCare] Customer Service Department at 1-800-624-8822.
[Below from pp. 20-21]
Your Medical Benefits
Inpatient Benefits
10. Transgender Surgery – Inpatient
Transgender surgery requires prior authorization from PacifiCare. Transgender
surgery and services related to the surgery that are authorized by PacifiCare
are subject to a combined Inpatient and Outpatient lifetime benefit maximum
of $75,000 for each Member. PacifiCare covers certain transgender surgery
and services related to the surgery to change a Member's physical characteristics
to those of the opposite gender. Travel expense reimbursement is limited
to reasonable expenses for transportation, meals, and lodging for the
Member to obtain authorized surgical consultation, transgender reassignment
surgical procedure(s), and follow-up care, when the authorized surgeon
and facility are located more than 200 miles from the Member's Primary
Residence. The transportation and lodging arrangements must be arranged
by or approved in advance by PacifiCare. Reimbursement excludes coverage
for alcohol and tobacco. Food and lodging expenses are not covered for
any day a Member is not receiving authorized transgender reassignment
services. Travel expenses are included in the $75,000 lifetime benefit
maximum.
[Below from p. 22]
Your Medical Benefits
Inpatient Benefits
16. Reconstructive Surgery – Reconstructive surgery is covered to
correct or repair abnormal structures of the body caused by congenital
defects, developmental abnormalities, trauma, infection, tumors or disease.
The purpose of reconstructive surgery is to correct abnormal structures
of the body to improve function or create a normal appearance to the extent
possible. Reconstructive procedures require Preauthorization by the Member's
Participating Medical Group or PacifiCare in accordance with standards
of care as practiced by Physicians specializing in reconstructive surgery.
PacifiCare covers certain transgender surgery and services related to
the surgery to change a Member's physical characteristics to those of
the opposite gender. Inpatient and Outpatient Services for transgender
surgery and services related to the surgery require prior authorization
by PacifiCare and are subject to a combined Inpatient and Outpatient lifetime
benefit maximum of $75,000 for each Member
[Below from p. 29]
Your Medical Benefits
Outpatient Benefits
34. Outpatient Transgender Services – Outpatient Services including
outpatient surgery services for transgender surgery, services related
to the surgery, outpatient office visit, and related services require
prior authorization by PacifiCare and are subject to a combined Inpatient
and Outpatient lifetime benefit maximum of $75,000 for each Member. PacifiCare
covers certain transgender surgery and services related to the surgery
to change a Member's physical characteristics to those of the opposite
gender.
[Below from p. 33]
Your Medical Benefits
III. Exclusions and Limitations of Benefits
Other Exclusions and Limitations
14. Cosmetic Services and Surgery – Cosmetic surgery and cosmetic
services are not covered. Cosmetic surgery and cosmetic services are defined
as surgery and services performed to alter or reshape normal structures
of the body in order to improve appearance. Drugs, devices and procedures
related to cosmetic surgery or cosmetic services are not covered. Cosmetic
surgeries or cosmetic services do not become reconstructive surgery because
of a Member's psychological or psychiatric condition. PacifiCare covers
certain transgender surgery and services related to the surgery to change
a Member's physical characteristics to those of the opposite gender. Inpatient
and Outpatient Services for transgender surgery and services related to
the surgery require prior authorization by PacifiCare and are subject
to a combined Inpatient and Outpatient lifetime benefit maximum of $75,000
for each Member.
No benefits are provided for:
a. Liposuction to reshape waist, hips, thighs and buttocks;
b. Cosmetic chest reconstruction or augmentation mammoplasty;
c. Electrolysis and laser hair removal, except when required as part of
covered
transgender genital reconstruction surgery;
d. Drugs for hair loss or growth;
e. Voice therapy or voice modification surgery;
f. Sperm or gamete procurement for future infertility or storage of sperm,
gametes, or
embryos;
g. Penile implant devices, penile device implantation, and penile implant
revision or
reinsertion;
h. Intersex surgery (transsexual operations) except as specifically provided
under the
"Limited Transgender Benefit" or treatment of any resulting
complications, unless that treatment is determined to be Medically Necessary.
[Below from p. 43]
Outpatient Prescription
Drug Program
Hormone drugs subject to the Harry Benjamin International Gender Dysphoria
Association's (HBIGDA) Standards of Care for Gender Identity Disorder.