Citi Benefits Handbook
Covered Services and Supplies
This list of covered services and supplies applies to all ChoicePlan 500, High Deductible Health Plan, and Oxford PPO medical plans sponsored by Citi, except where noted.
Covered services and supplies must be medically necessary and related to the diagnosis or treatment of an accidental injury, sickness, or pregnancy. Reimbursement for all covered services and supplies listed in this section are subject to maximum allowed amount (MAA) or, for in-network services, the negotiated rates of the plan.
You and your physician decide which services and supplies are required, but the plan pays only for the following covered services and supplies that are medically necessary as determined by the Claims Administrators.
Covered services and supplies also include services and supplies that are part of a case management program. A case management program is a course of treatment developed by the Claims Administrator as an alternative to the services and supplies that would otherwise have been considered covered services and supplies. Unless the case management program specifies otherwise, the provisions of the plan related to benefit amounts, maximum amounts, copayments, and deductibles will apply to these services.
Acupuncture
Acupuncture must be administered by a medical doctor or a licensed acupuncturist (if state license is available).
Aetna: Acupuncture is covered for the following:
  • Pain management, treatment for nausea related to pregnancy and post-operative and chemotherapy-induced nausea and vomiting
  • Chronic low back pain (Maintenance treatment, where the patient's symptoms are neither regressing nor improving, is considered not medically necessary. If no clinical benefit is appreciated after four weeks, then the treatment plan should be re-evaluated)
  • Migraine headache
  • Pain from osteoarthritis of the knee or hip (adjunctive therapy; if no clinical benefit is appreciated after four weeks, then the treatment plan should be reevaluated)
  • Post-operative dental pain
  • Temporomandibular disorders (TMD)
Anthem: Acupuncture is covered with no visit limits or diagnosis requirements.
Oxford: Acupuncture is covered if administered by a medical doctor, an osteopathic physician, a chiropractor, or a licensed acupuncturist (if state license is available).
Adult Immunizations
The following are the guidelines for covered adult immunizations:
  • Tetanus, diphtheria (Td): Booster every 10 years;
  • Influenza (flu): Annual for adults under age50 and at risk; annual for adults age50 plus;
  • Pneumococcal vaccine (PPV): Once for adults under age50 with risk factors with booster after five years for adults at highest risk and those most likely to lose their immunity; once at age65 with booster after five years if less than 65 at the time of primary vaccination;
  • Varicella (chicken pox): Persons under age50 with no history of varicella and who test negative for immunity. Persons over age50 are assumed to be immune. Note: Women who are pregnant (or planning to become pregnant in the four weeks following vaccination) should NOT be vaccinated;
  • Measles, mumps, rubella (MMR): For people born after 1956 — two doses measles with additional doses as MMR; people born before 1957 can be considered immune. Note: Women who are pregnant (or planning to become pregnant in the four weeks following vaccination) and people whose immune system is not working properly should NOT be vaccinated;
  • Hepatitis A: Only those at risk; those at risk, two doses at least six months apart;
  • Hepatitis B: Immunize if age46 or under; if over age45, only those at high risk; if at risk, three doses (second dose one to two months after the first dose, and the third dose no earlier than two months after the first dose and four months after the second dose);
  • Meningococcal: Meningitis (only those at risk); if at increased risk, one dose (an additional dose may be recommended for those who remain at high risk);
  • Tuberculin skin test: Annual testing for high-risk group (method: Five tuberculin units of PPD);
  • Gardasil vaccine for HPV: Males and females age9 years to 26 years (age restrictions do not apply to Anthem Blue Cross and Blue Shield); and
  • Zostavax vaccine for shingles: Adults age60 or older.
Ambulatory Surgical Center
A center's services given within 72 hours before or after a surgical procedure. The services must be given in connection with the procedure.
Anesthetics
Drugs that produce loss of feeling or sensation either generally or locally, except when done for dental care not covered by the plan. When administered as part of a medical procedure, anesthesia must be administered by a board-certified anesthesiologist. Anesthesia is not covered when rendered in the doctor's office or when administered by the operating surgeon, unless it is administered by a dentist for dental care that is covered by the plan.
Note: The Oxford PPO will cover this service when medically necessary and appropriate.
Autism Assistance Benefits
If you enroll in an Anthem, Aetna, or Oxford medical plan, family members who have been diagnosed with autism spectrum disorders have access to autism assistance benefits, including Applied Behavior Analysis (ABA) therapy.
Members diagnosed with Autism Spectrum Disorder (ASD) have coverage available for the diagnosis and treatment of ASD, when ordered by a physician, licensed psychologist, or licensed clinical social worker as part of a treatment plan.
Baby Care
The following services and supplies given during an eligible newborn child's initial hospital confinement:
  • Hospital services for nursery care;
  • Other services and supplies given by the hospital;
  • Services of a surgeon for circumcision in the hospital; and
  • Physician services.
Note: If the newborn child is discharged at the same time as the mother, then the charges for the services rendered for the child are subject to coinsurance only. The mother's claims are subject to the deductible and coinsurance. If the newborn child remains in the hospital longer than the mother, the claims for the child apply to his or her own deductible and coinsurance limits if the member has not already met the family limits.
Please note: If your covered dependent child gives birth, only the services for your dependent child are covered. Your newborn grandchild is not eligible for coverage.
Birth Center
Room and board and other services, supplies, and anesthetics.
Cancer Detection
Diagnostic screenings not subject to precertification or notification include:
  • Mammogram;
  • Pap smear;
  • Prostatic-specific antigen (PSA);
  • Sigmoidoscopy; and
  • Colonoscopy.
Chemotherapy
For cancer treatment.
Contraceptive Services/Devices
Contraceptive services and devices including, but not limited to:
  • Diaphragm and intrauterine device and related physician services;
  • Voluntary sterilization including vasectomy, tubal ligation, sterilization implants and surgical sterilizations;
  • Injectables such as Depo-Provera; and
  • Surgical implants for contraception, such as Mirena or Norplant.
Cryopreservation
Aetna: Cryopreservation of mature oocytes or embryos is considered medically necessary for use in IVF/ICSI cycles, and for use in women facing infertility due to chemotherapy, pelvic radiotherapy, or other gonadotoxic therapies with no storage time limitation. Cryopreservation of sperm is considered medically necessary in men facing infertility due to chemotherapy, pelvic radiotherapy, or other gonadotoxic therapies with no storage time limitation.
Anthem BlueCross BlueShield: Cryopreservation of mature oocytes is considered medically necessary in post-pubertal females facing anticipated infertility resulting from chemotherapy or radiation therapy.
Oxford: Fertility preservation prior to gonadotoxic treatment including sperm, mature egg (women under the age of 42), or embryo cryopreservation with storage up to one year.
Dietitian/Nutritionist
Nutritional counseling is covered by a licensed dietitian and/or licensed nutritionist for diabetes, bulimia, anorexia nervosa, and morbid obesity.
Durable Medical Equipment
Durable medical equipment means equipment that meets all of the following:
  • It is for repeated use and is not a consumable or disposable item;
  • It is used primarily for a medical purpose; and
  • It is appropriate for use in the home.
Some examples of durable medical equipment are:
  • Appliances that replace a lost body part or organ or help an impaired organ or part;
  • Orthotic devices such as arm, leg, neck, and back braces;
  • Hospital-type beds;
  • Equipment needed to increase mobility, such as a wheelchair;
  • Respirators or other equipment for the use of oxygen; and
  • Monitoring devices (e.g., blood glucose monitor).
Each Claims Administrator decides whether to cover the purchase or rental of the equipment based on coverage guidelines. Changes made to your home, automobile, or personal property are not covered. Rental coverage is limited to the purchase price of the durable medical equipment. Replacement, repair, and maintenance are covered only if:
  • They are needed due to a change in your physical condition or
  • It is likely to cost less to buy a replacement than to repair the existing equipment or rent similar equipment.
Foot Care
Care and treatment of the feet, if afflicted by severe systemic disease. Routine care such as removal of warts, corns, or calluses; the cutting and trimming of toenails; and foot care for flat feet, fallen arches, and chronic foot strain is covered only if needed due to severe systemic disease. Note: foot care is not covered under the Oxford PPO plan.
  • Aetna and Anthem BlueCross BlueShield ChoicePlan 500 cover the services of a podiatrist for the treatment of a disease or injury, including the treatment of corns, calluses, keratoses, bunions, and ingrown toenails.
Hearing Aids
Hearing aids are covered, regardless of the reason for hearing loss.
  • Adults: Once every three calendar years.
  • Children: Once every two calendar years.
Home Health Care (Combined with Private-Duty Nursing)
The following covered services must be given by a home health care agency:
  • Temporary or part-time skilled nursing care by or supervised by a registered nurse (RN) or licensed practical nurse (LPN)
  • Medical social services provided by, or supervised by, a qualified physician or social worker if your physician certifies with the plan that the medical social services are necessary for the treatment of your medical condition.
Covered services are limited to 200 visits each calendar year (combined visits with private-duty nursing), and you must notify the plan in advance. Each period of home health aide care of up to eight hours given in the same day counts as one visit. Each visit by any other member of the home health team will count as one visit. Multiple services provided on the same day count as one visit and are billed by the same provider on the same bill. Visits may be increased with prior approval from your health plan.
Hospice Care
Hospice services for a participant who is terminally ill include:
  • Room and board coverage limited to expenses for the regular daily charge made by the hospital for a semiprivate room (or private room when medically appropriate or if it is the only room type available);
  • Other services and supplies prescribed by a physician to keep the patient comfortable while in hospice care;
  • Part-time nursing care by or supervised by a RN or LPN;
  • Home health care services as shown under home health care; the limit on the number of visits shown under home health care does not apply to hospice patients;
  • Counseling for the patient and covered dependents;
  • Pain management and symptom control; and
  • Bereavement counseling for covered dependents; services must be given within six months of the patient's death, and covered services are limited to a total of 15 visits for each family member.
    • For Aetna ChoicePlan 500,Anthem BlueCross BlueShield ChoicePlan 500, and Oxford Health Plans, bereavement counseling is covered under the mental health benefit. Mental Health benefits do not have visit limits.
Bereavement counseling must be provided by a licensed counselor. Services for the patient must be given in an inpatient hospice facility or in the patient's home. The physician must certify that the patient is terminally ill with six months or less to live. Any counseling services given in connection with a terminal illness will not be considered as mental health and substance abuse treatment for purposes of applying the mental health/substance abuse maximum visit limit.
Hospital Services
Aetna and Anthem BlueCross BlueShield: Hospital services include:
  • Room and board: Covered expenses are limited to the regular daily charge made by the hospital for a semiprivate room (or private room when medically appropriate);
  • Other services and supplies, including:
    • Intensive or special care facilities when medically appropriate;
    • Visits by your physician while you are confined;
    • General nursing care;
    • Surgical, medical, and obstetrical services;
    • Use of operating rooms and related facilities;
    • Medical and surgical dressings, supplies, casts, and splints;
    • Drugs and medications;
    • Intravenous injections and solutions;
    • Nuclear medicine; and
    • Preoperative care and post-operative care:
      • Administration and processing of blood;
      • Anesthesia and anesthesia services;
      • Oxygen and oxygen therapy;
      • Inpatient physical and rehabilitative therapy, including cardiac and pulmonary rehabilitation;
      • X-rays, laboratory tests, and diagnostic services; and
      • Magnetic resonance imaging (MRI).
Oxford: Hospital Inpatient services for medically necessary, acute-care includes:
  • Semi-private room and board, unlimited days,
  • General nursing care,
  • Services and supplies, including:
    • Meals and special diets;
    • Use of operating room and related facilities;
    • Use of intensive care or cardiac care units and related services;
    • X-ray services; laboratory and other diagnostic tests;
    • Drugs; medications; biologicals; anesthesia and oxygen services;
    • Short-term physical, speech and occupational therapy; radiation therapy; inhalation therapy; chemotherapy;
    • Whole blood and blood products; and the administration of whole blood and blood products.
Emergency room services are covered only if determined to be medically appropriate and there is not a less intensive or more appropriate place of service, diagnostic, or treatment alternative that could have been used. If your health plan, at its discretion, determines that a less intensive or more appropriate treatment could have been given, then no benefits are payable.
Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, to discharge the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours as applicable). Authorizations are required for longer stays.
Infertility Treatment
Aetna:
Treatment of infertility must be pre-authorized. Penalties apply if the treatment is received without pre-certification.
  • Basic Infertility Expenses: Covered expenses include charges made by a physician to diagnose and to surgically treat the underlying medical cause of infertility. These expenses do not count towards the medical lifetime maximum.
  • Comprehensive Infertility and Advanced Reproductive Technology (ART) Expenses: To be an eligible covered female for benefits you must be covered as an employee, or be a covered dependent who is the employee's spouse/partner. Even though not incurred for treatment of an illness or injury, covered expenses will include expenses incurred by an eligible covered female for infertility if all of the following tests are met:
    • A condition that is a demonstrated cause of infertility which has been recognized by a gynecologist, or an infertility specialist, and your physician who diagnosed you as infertile, and it has been documented in your medical records.
    • The procedures are done while not confined in a hospital or any other facility as an inpatient.
    • Your FSH levels are less than, 19 miU on day 3 of the menstrual cycle.
    • The infertility is not caused by voluntary sterilization of either one of the partners (with or without surgical reversal); or a hysterectomy.
    • A successful pregnancy cannot be attained through less costly treatment for which coverage is available under this plan.
  • Comprehensive Infertility Services Benefits: If you meet the eligibility requirements above, the following comprehensive infertility services expenses are payable when provided by an infertility specialist upon pre-certification by Aetna, subject to all the exclusions and limitations.
    • Ovulation induction with menotropins is subject to the maximum benefit and
    • Intrauterine insemination is subject to the maximum benefit.
  • Advanced Reproductive Technology (ART) Benefits: ART is defined as:
    • In vitro fertilization (IVF);
    • Zygote intrafallopian transfer (ZIFT);
    • Gamete intra-fallopian transfer (GIFT);
    • Cryopreserved embryo transfers;
    • Intracytoplasmic sperm injection (ICSI); or ovum microsurgery.
    • ART services for procedures that are covered expenses.
  • Eligibility for ART Benefits: To be eligible for ART benefits, you must meet the requirements above and:
    • Coverage for ART services is available only if comprehensive infertility services do not result in a pregnancy in which a fetal heartbeat is detected;
    • Be referred by your physician to Aetna's infertility case management unit;
    • Obtain pre-certification from Aetna's infertility case management unit for ART services by an ART specialist.
  • Covered ART Benefits: The following charges are covered benefits for eligible covered females when all of the above conditions are met, subject to the Exclusions and Limitations
    • Subject to the maximum benefit of any combination of the following ART services per lifetime (where lifetime is defined to include all ART services received, provided or administered by Aetna or any affiliated company of Aetna) which only include: IVF; GIFT; ZIFT; or cryopreserved embryo transfers;
    • IVF; Intra-cytoplasmic sperm injection ("ICSI"); ovum microsurgery; GIFT; ZIFT; or cryopreserved embryo transfers subject to the maximum benefit;
    • Payment for charges associated with the care of the an eligible covered person under this plan who is participating in a donor IVF program, including fertilization and culture; and
    • Charges associated with obtaining the spouse's sperm for ART, when the spouse is also covered under the plan
Anthem BlueCross BlueShield and Oxford:
Diagnosis of infertility and surgical correction of a medical condition causing infertility are covered subject to the plan's copayment or deductible and coinsurance.
Covered services include:
  • Services for diagnosis and treatment of the underlying medical condition:
    • Initial evaluation, including history, physical exam, and laboratory studies;
    • Physical lab work including genetic testing, psychological evaluations, medications to synchronize the cycle of the donor with the cycle of the recipient and to stimulate the ovarian function of the donor;
    • Evaluation of ovulation function;
    • Ultrasound of ovaries;
    • Post-coital test;
    • Hysterosal pingogram;
    • Endometrial biopsy;
    • Hysteroscopy; and
    • Semen analysis for male participants.
  • Advanced reproductive services:
    • Ovulation induction cycle with menotropins;
    • Harvesting of plan participant's eggs;
    • Artificial insemination;
    • Infertility surgery (diagnostic or therapeutic);
    • ART services and treatment, including in-vitro fertilization (IVF), Gamete Intrafallopian Transfer (GIFT), Zygote Intrafallopian Transfer (ZIFT), and cryopreserved embryo transfer and Frozen Embryo Transfer (FET);
  • Medical expenses for infertility treatment are covered up to a family lifetime maximum of $24,000. Only expenses for advanced services (e.g., IVF, GIFT, ZIFT) and comprehensive services (e.g., artificial insemination) accumulate towards the lifetime maximum. Expenses for diagnosis and treatment of the underlying medical condition do not count towards the lifetime maximum.
  • Prescription drug expenses associated with infertility treatment are covered up to a lifetime maximum of $7,500 per family under the Citigroup Health Benefits Plan, through the Prescription Drugs section.
  • Covered services do not include the costs associated with surrogate mothers and the costs of donating donor eggs.
HMOs
Each HMO offers different infertility coverage and limits, if at all. Check with your HMO for details of infertility coverage.
Laboratory Tests/X-Rays
X-rays or tests for diagnosis or treatment.
Licensed Counselor Services
Services of a licensed counselor for mental health and substance abuse treatment.
Medical Care
  • Hospital, office, and home visits; and
  • Emergency room services.
Medical Supplies
  • Surgical supplies (such as bandages and dressings). Supplies given during surgery or a diagnostic procedure are included in the overall cost for that surgery or diagnostic procedure; and
  • Blood or blood derivatives:
Aetna and Anthem BlueCross BlueShield:
  • Autologous blood donation: The donation of your own blood for use during a scheduled covered surgical procedure;
  • Directed blood donation: The donation of blood by a person chosen by the patient to donate blood for the patient's use during a scheduled covered surgical procedure;
  • Autologous or directed blood donation prior to a scheduled surgery when it generally requires blood transfusions and the provider/organization that obtains and processes the blood makes a charge that the patient is legally obligated to pay; and
    • Aetna: Blood, blood products, processing, storage and administration. Blood and blood products such as platelets or plasma are reimbursable. Blood product processing fees (typing, serology and cross-matching and blood storage) are also reimbursable. However, transportation charges are included in the reimbursement for the product itself and are not separately reimbursable. Note: Routine harvesting and storage from stem cells from new born cord blood is not covered. However, Aetna covers stem cells for hematopoietic cell transplant when deemed medically necessary according to the following criteria: Aetna considers compatibility testing of prospective donors who are close family members (first-degree relatives (i.e., parents, siblings and children)or second degree relatives (i.e., grandparent, grandchild, uncle, aunt, nephew, niece, half-sibling))and harvesting and short-term storage of peripheral stem cells or bone marrow from the identified donor medically necessary when an allogeneic bone marrow or peripheral stem cell transplant is authorized by Aetna.
    • Aetna considers umbilical cord blood stem cells an acceptable alternative to conventional bone marrow or peripheral stem cells for allogeneic transplant.
    • Aetna considers medically necessary the short-term storage of umbilical cord blood for a member with a malignancy undergoing treatment when there is a match. Note: The harvesting, freezing and/or storing umbilical cord blood of non-diseased persons for possible future use is not considered treatment of disease or injury. Such use is not related to the person's current medical care.
    • Anthem BlueCross BlueShield: Blood, blood products, processing, storage and administration. Blood and blood products such as platelets or plasma are reimbursable. Blood product processing fees (typing, serology and cross-matching and blood storage) are also reimbursable. However, transportation charges are included in the reimbursement for the product itself and are not separately reimbursable. Blood and blood product administration services are reimbursable only on an outpatient basis when billed hourly or as a flat rate with total eligible charges capped at the average approved semi-private room rate.
The use of umbilical cord blood progenitor cell transplantation is considered medically necessary for selected individuals when all of the following criteria are met:
      • One or two donor cord unit(s) is used for a single recipient; and
      • The total nucleated cell (TNC) count is equal to or greater than 2.3 x 107 per kg; and
      • The umbilical cord blood stem cell unit(s) is used for an allogeneic stem cell transplant for an approved indication and the appropriate stem cell transplant criteria are met.
Collection and storage of cord blood is considered medically necessary only when an allogeneic transplant is imminent for an identified recipient and the above criteria are met. Storage will only be authorized at centers approved by one of the following accreditation bodies:
      • Foundation for Accreditation of Cellular Therapy (FACT);
      • National Cancer Institute (NCI);
      • AABB (formerly known as American Association of Blood Banks);
      • California Department of Public Health
Investigational and Not Medically Necessary: The use of umbilical cord blood progenitor cell transplantation is considered investigational and not medically necessary when it does not meet the criteria listed above.
Prophylactic collection and storage of umbilical cord blood is considered investigational and not medically necessary when proposed for an unspecified future use for an autologous stem cell transplant in the original donor or for an unspecified future use as an allogeneic stem cell transplant in a related or unrelated donor.
Oxford: Autologous blood banking services are covered only when they are being provided in connection with a scheduled, covered inpatient procedure for the treatment of a disease or injury. In such instances, the plan will cover storage fees for what Oxford determines to be a reasonable storage period that is medically necessary and appropriate for having the blood available when it is needed. Routine harvesting and storage of stem cells from newborn cord blood is not covered under any circumstances. This service is not proven to be clinically effective and, therefore, is considered to be unproven and not medically necessary.
Medical Transportation Services
Transportation by professional ambulance or air ambulance to and from the nearest medical facility qualified to give the required treatment. These services must be given within the United States, Puerto Rico, and Canada.
  • Aetna ChoicePlan 500 and Anthem BlueCross BlueShield ChoicePlan 500.
  • Air ambulance requiring a transport to a hospital or from one hospital to the nearest hospital because the first hospital does not have the required services and/or facilities to treat the member; and ground ambulance is not medically appropriate. Air ambulance for member convenience or non-clinical reason is not covered.
  • Oxford Health Plans: When a member has traveled out of the country, emergency or 911 transportation to the nearest hospital and/or hospital emergency facility does not require notification, precertification, or certification. However, Oxford Medical Management should be notified of an admission within 48 hours or as soon as possible, consistent with the member's certificate. All requests for other out-of-the-country transportation require precertification and Medical Director review.
The health plans cover professional ambulance service on a standard basis to transport the individual from the place where he/she is injured or stricken by disease to the first hospital where treatment is given. Ambulettes are not covered.
Morbid Obesity Expenses (Non-HMO/PPO Plans)
Covered medical expenses include charges made on an inpatient or outpatient basis by a hospital or a physician for the surgical treatment of morbid obesity of a covered person. Limitations apply. For more information, contact your plan directly.
Dietician/nutritionist coverage is also available for morbid obesity. See "Dietitian/Nutritionist."
Nurse-Midwife
Services of a licensed or certified nurse-midwife. Maternity-related benefits are payable on the same basis as services given by a physician.
Nurse-Practitioner
Services of a licensed or certified nurse-practitioner acting within the scope of that license or certification. Benefits are payable on the same basis as covered services given by a physician.
Oral Surgery/Dental Services
The plan pays first (the primary plan) for oral surgery if needed as a necessary, but incidental, part of a larger service in treatment of an underlying medical condition.
The following oral surgeries are considered medical in nature and covered under the medical plan as necessary:
  • Treat a fracture, dislocation, or wound;
  • Cut out:
    • Teeth partly or completely impacted in the bone of the jaw;
    • Teeth that will not erupt through the gum;
    • Other teeth that cannot be removed without cutting into bone;
    • The roots of a tooth without removing the entire tooth; and
    • Cysts, tumors, or other diseased tissues.
  • Cut into gums and tissues of the mouth. This is covered only when not done in connection with the removal, replacement, or repair of teeth; and
  • Alter the jaw, jaw joints, or bite relationships by a cutting procedure when appliance therapy alone cannot result in functional improvement
  • If oral surgery/dental services are needed in connection with an accident or injury
    • Aetna requires that any treatment must be completed in the calendar year of the accident or in the next calendar year unless postponed due to a patient's physical condition.
  • If crowns, dentures, bridges, or in-mouth appliances are installed due to injury, covered expenses only include charges for:
    • The first denture or fixed bridgework to replace lost teeth;
    • The first crown needed to repair each damaged tooth; and
    • An in-mouth appliance used in the first course of orthodontic treatment after the injury.
    • Any such teeth must have been free from decay or in good repair, and are firmly attached to the jaw bone at the time of the injury.
  • Anthem BlueCross BlueShield accepts the following oral surgeries as medical in nature and covered under the medical plan as necessary:
    • Extraction of impacted wisdom teeth;
    • Services to treat an injury to sound natural teeth that are given within 12 months of accident/injury;
    • TMJ surgery; and
    • Anesthesia for dental services only when the dental service itself is covered, is administered by an anesthesiologist and is done outside of the doctor's office.
Corrective surgery is covered if medically necessary for purposes of chewing and speaking.
The following services and supplies are covered only if needed because of accidental injury to sound and natural teeth that happened to you or your dependent while covered under this plan. Treatment must be received within 12 months of the accident/injury.
  • Oral surgery;
  • Full or partial dentures;
  • Fixed bridgework;
  • Prompt repair to sound and natural teeth; and
  • Crowns.
Oxford Health Plans accepts the following oral surgeries as medical in nature and covered under the medical plan as necessary:
  • Extraction of impacted wisdom teeth;
  • Services to treat an injury to sound natural teeth; and
  • TMJ surgery.
  • Note: Oxford does not cover general dental care. Coverage is available for the following limited dental and oral surgical procedures:
    • Oral surgery for the repair of sound natural teeth, jaw bones, or surrounding tissue which is related to accidental injury.
    • Treatment for tumors or cysts requiring pathological examinations of the jaw, cheek, lip, tongue, or roof or floor of the mouth.
    • TMJ surgery is covered. All surgery must be precertified in advance through Oxford's Medical Management Department.
  • Care may be accessed on either an in-network or out-of-network basis. Pre-certification is required.
Organ/Tissue Transplants
Keep in mind that qualified transplant procedures will be covered at the out-of-network level when performed at a facility that is not deemed a Center of Excellence (COE) [or Blue Distinction Center (BDC) through BlueCross BlueShield]. Contact your plan for more information about locating a COE (or BDC).
Your Claims Administrator must be notified before the scheduled date (or as soon as reasonably possible) of any of the following:
  • The evaluation;
  • The donor search;
  • The organ procurement/tissue harvest; and
  • The transplant procedure.
  • Anthem BlueCross BlueShield and Aetna do not require precertification within a certain number of days, but Oxford requires precertification within at least 14 days.
Donor charges for organ/tissue transplants
  • In the case of an organ or tissue transplant, donor charges are considered covered expenses only if the recipient is a covered person under the plan. If the recipient is not a covered person, no benefits are payable for donor charges.
  • The search for bone marrow/stem cell from a donor who is not biologically related to the patient is not considered a covered service unless the search is made in connection with a transplant procedure arranged by a designated transplant facility.
    • Aetna, Anthem BlueCross Blue Shield and Oxford cover donor search fees through the National Marrow Donor Program.
Qualified procedures
If a qualified procedure, listed in this section, is medically necessary and performed at a designated transplant facility, the "medical care and treatment" and "transportation and lodging" provisions described in this section apply.
  • Heart transplants;
  • Lung transplants;
  • Heart/lung transplants;
  • Liver transplants;
  • Kidney transplants;
  • Pancreas transplants;
  • Kidney/pancreas transplants;
  • Bone marrow/stem cell transplants; and
  • Other transplant procedures when your Claims Administrator determines that they are medically necessary to perform the procedure as a designated transplant.
For Aetna, transplant services are covered as long as the transplant is not experimental or investigational and has been approved in advance. Transplants must be performed in hospitals specifically approved and designated by Aetna to perform the procedure. The Institutes of Excellence (IOE) network is Aetna's network of providers for transplants and transplant-related services, including evaluations and follow-up care. Each facility has been selected to perform only certain types of transplants, based on its quality of care and successful clinical outcomes.
For Aetna plans (CP500 and HDHP), a transplant will be covered as an in-network service only if performed in a facility that has been designated as an IOE facility for the type of transplant in question. Any facility that is not specified as an Institute of Excellence network facility is considered a non-participating facility for transplant-related services, even if the facility is considered a participating facility for other types of services.
Members must receive precertification for transplant procedures. When a member or physician calls Aetna to precertify a transplant evaluation, a case nurse will direct him or her to an IOE facility.
For Anthem BlueCross BlueShield, coverage is based on the facility used for the transplant. If a Blue Distinction Center (BDC or BDC+) is used, the service will be covered at 80% with access to the travel and lodging benefit. Blue Distinction Centers meet stringent clinical criteria, established in collaboration with expert physician panels and national medical societies, including the Center for International Blood and Marrow Transplant Research (CIBMTR), the Scientific Registry of Transplant Recipients (SRTR), and the Foundation for the Accreditation of Cellular Therapy (FACT), and are subject to periodic re-evaluation as criteria continue to evolve. Call Anthem at 1 (855) 593-8123 for additional coverage information as well as assistance in locating a BDC or BDC+ facility.
Precertification is required for these services. Services performed at BDC or BDC+ facilities are covered at 80% with access to the travel and lodging benefit; all other facilities are covered at 60% with no access to the travel and lodging benefit. If care at a BDC or BDC+ facility requires you to travel 75 miles or more from your home, you'll have access to a travel and lodging benefit, with a maximum of $10,000 per surgery or treatment.
Medical Care and Treatment
Covered expenses for services provided in connection with the transplant procedure include:
  • Pretransplant evaluation for one of the procedures listed above;
  • Organ acquisition and procurement;
  • Hospital and physician fees;
  • Transplant procedures;
  • Follow-up care for a period of up to one year after the transplant;
  • Search for bone marrow/stem cell from a donor who is not biologically related to the patient. If a separate charge is made for bone marrow/stem cell search, a maximum benefit of $25,000 is payable for all charges made in connection with the search. Note: Coverage of donor costs is generally limited to medically necessary procedures, inpatient confinement (e.g., semi-private room and board in an acute hospital setting) and a postoperative global period not to exceed 180 calendar days. (This maximum applies to the Oxford PPO. It does not apply to the Aetna and Anthem BlueCross BlueShield plans.)
  • When available, the plan will assist the patient and family with travel and lodging arrangements when a qualified procedure, listed in this section, is medically necessary and performed at a designated center of excellence facility. Expenses for travel and lodging for the transplant recipient and a companion are available as follows:
  • Transportation, including expenses for personal car mileage at the current federal rate of reimbursement, of the patient and one companion who is traveling on the same day(s) to and/or from the site of the transplant procedure for an evaluation, the transplant procedure, or necessary post-discharge follow-up;
  • Reasonable and necessary expenses for lodging for the patient (while not confined) and one companion. Benefits are paid at a per-diem rate of $50 for one person or $100 a day for two people (a maximum of $50 per person — $100 for patient and companion combined— per night is paid toward lodging expenses; meals are not covered);
  • Travel and lodging expenses are available only if the transplant recipient resides more than 75 miles from the designated facility for Aetna, BlueCross BlueShield or Oxford plans;
  • If the patient is a covered dependent minor child, the transportation expenses of two companions will be covered; lodging expenses will be reimbursed at the $100 per-diem rate;
  • A combined overall lifetime maximum of $10,000 per covered person, per occurrence, for all transportation and lodging expenses incurred by the transplant recipient and companion (companions, if the covered dependent is a minor) and reimbursed under the plan in connection with all transplant procedures.
If the covered person chooses not to receive his or her care in connection with a qualified procedure pursuant to this organ/tissue transplant section, the services and supplies received by the covered person in connection with that qualified procedure will be paid under the plan if and to the extent covered by the plan without regard to this organ/tissue transplant section.
  • There may be some differences in coverage for transportation and lodging.
Oxford Health Plans covers only those solid organ transplants that are non-experimental and non-investigational. All transplants must be performed by a UNOS (United Network for Organ Sharing)-participating academic transplant center. All solid organ transplants must be performed in facilities that Oxford has specifically contracted and designated to perform these procedures to be eligible for plan coverage.
The following types of solid organ transplants will be covered when performed by a UNOS-participating academic transplant center:
  • Heart transplant;
  • Lung transplant;
  • Heart-lung transplant;
  • Liver transplant;
  • Kidney transplant;
  • Intestinal and multi-visceral transplants; and
  • Pancreas transplant.
For more information, contact your Claims Administrator directly.
Orthopedic Surgery
Keep in mind that qualified orthopedic procedures will be covered at the out-of-network level when performed at a facility that is not deemed a Center of Excellence (COE) [or a Blue Distinction Center (BDC or BDC+) through BlueCross BlueShield]. Contact Member Services at your Health Carrier for more information about locating a COE (or BDC).
Qualified Procedures
If a qualified procedure, listed in this section, is medically necessary and performed at a designated center of excellence facility, the "medical care and treatment" and "transportation and lodging" provisions described in this section apply.
  • Total knee replacement;
  • Total hip replacement; and
  • Spine surgery (discectomy, spinal fusion, spinal decompression)
When available, the plan will assist the patient and family with travel and lodging arrangements when a qualified procedure, listed in this section, is medically necessary and performed at a designated center of excellence facility. Expenses for travel and lodging for the orthopedic recipient and a companion are available as follows:
  • Transportation, including expenses for personal car mileage at the current federal rate of reimbursement, of the patient and one companion who is traveling on the same day(s) to and/or from the site of the orthopedic procedure for an evaluation, the orthopedic procedure, or necessary post-discharge follow-up;
  • Reasonable and necessary expenses for lodging for the patient (while not confined) and one companion. Benefits are paid at a per-diem rate of $50 for one person or $100 a day for two people (a maximum of $50 per person — $100 for patient and companion combined — per night is paid toward lodging expenses; meals are not covered);
  • Travel and lodging expenses are available only if the orthopedic recipient resides more than 75 miles from the designated facility for Aetna, BlueCross BlueShield plans;
  • If the patient is a covered dependent minor child, the transportation expenses of two companions will be covered; lodging expenses will be reimbursed at the $100 per-diem rate; 
  • A combined overall lifetime maximum of $10,000 per covered person, per occurrence, for all transportation and lodging expenses incurred by the orthopedic recipient and companion (companions, if the covered dependent is a minor) and reimbursed under the plan in connection with all orthopedic procedures.
For Anthem BlueCross BlueShield, coverage is based on the facility used for the transplant. If a Blue Distinction Center (BDC or BDC+) is used, the procedure will be covered at 80%. Blue Distinction Centers meet stringent clinical criteria, established in collaboration with expert physician panels and national medical societies and are subject to periodic re-evaluation as criteria continue to evolve. Call Anthem at 1 (855) 593-8123 for additional coverage information as well as assistance in locating a BDC or BDC+ facility.
Precertification is required for these services. Services performed at BDC or BDC+ facilities are covered at 80% benefit; all other facilities are covered at 60%.If care at a BDC or BDC+ facility requires you to travel 75 miles or more from your home, you'll have access to a travel and lodging benefit, with a maximum of $10,000 per surgery or treatment. There is no travel and lodging benefit for services rendered outside of a Blue Distinction Center.
Orthoptic Training
Training by a licensed optometrist or an orthoptic technician. The plan covers a hidden ocular muscle condition where the eyes have a tendency to under converge or over converge. Manifest conditions of exotropia (turning out) or esotropia (turning in) are covered. Coverage is limited to 32 visits per calendar year.
Outpatient Occupational Therapy
Outpatient Physical Therapy
Prescribed Drugs
Prescribed drugs and medicines for inpatient services.
Preventive Care
Covered expenses include:
  • Routine physical exam (including a well-woman exam) is covered subject to frequency limits;
  • Routine immunizations;
  • Smoking cessation; and
  • Screening and counseling for obesity for adults and children.
A $250 calendar year maximum applies to out-of-network services per covered family member.
For more specific information regarding what is concerned to be Preventive Care, see "Preventive Care."
Private-Duty Nursing Care (combined with Home Health Care)
Private-duty nursing care is given on an outpatient basis by a RN, LPN, or licensed vocational nurse (LVN). This service must be approved by your Claims Administrator.
  • Aetna CP500 and Anthem BlueCross BlueShield CP500: A combined in-network and out-of-network maximum benefit of 200 visits per calendar year (combined with home health care visits) applies. One visit is equal to one eight-hour shift. Inpatient private-duty nursing is not covered. Precertification is required. Additional visits may be covered if approved in advance by your plan.
  • Oxford Health Plans: Private-duty nursing services are covered as medically necessary. A combined in-network and out-of-network maximum benefit of 200 visits per calendar year (combined with home health care visits) applies. One visit is equal to one four-hour shift. Inpatient private-duty nursing is not covered.
Psychologist Services
Services of a psychologist for psychological testing and psychotherapy.
Rehabilitation Therapy
Defined as short-term occupational therapy, physical therapy, speech therapy, and spinal manipulation:
  • Services of a licensed occupational or physical therapist, provided the following conditions are met:
    • The therapy must be ordered and monitored by a licensed physician (when required by state law); and
    • The therapy must be given according to a written treatment plan approved by a licensed physician. The therapist must submit progress reports at the intervals stated in the treatment plan;
  • Services of a licensed speech therapist. These services must be given to restore speech lost or impaired due to one of the following:
    • Surgery, radiation therapy, or other treatment that affects the vocal chords;
    • Cerebral thrombosis (cerebral vascular accident);
    • Brain damage due to accidental injury or organic brain lesion (aphasia);
    • Accidental injury that happens while the person is covered under the plan;
    • Chronic conditions (such as cerebral palsy or multiple sclerosis); or
    • Developmental delay (including Down syndrome).
Inpatient
  • Services of a hospital or rehabilitation facility for room, board, care, and treatment during a confinement. Coverage for room and board is limited to expenses for the regular daily charge made by the hospital for a semiprivate room (or private room when medically appropriate or if it is the only room type available).
  • Inpatient rehabilitative therapy is a covered service only if intensive and multidisciplinary rehabilitation care is necessary to improve the patient's ability to function independently.
Outpatient
  • Services of a hospital, comprehensive outpatient rehabilitative facility (CORF), or licensed therapist as described above.
  • Coverage includes short-term cardiac rehabilitation following angioplasty, cardiovascular surgery, congestive heart failure, or myocardial infarction.
  • Coverage includes short-term pulmonary rehabilitation for the treatment of reversible pulmonary disease.
  • All visit limits apply for both in-network and out-of-network, wherever the services are being provided, for example, at home, at a therapist's office, or in a free-standing therapy facility.
  • CP500 and HDHP: Spinal manipulation therapy limited to 20 visits per calendar year. Physical and occupational therapies combined are limited to 60 visits per calendar year. Speech therapy is limited to 90 visits per calendar year.
  • Oxford: Spinal manipulation therapy limited to 20 visits per calendar year. Physical, speech and occupational therapies combined are limited to 90 visits per calendar year. Additional visits available at a reduced coinsurance.
Routine Care
Covered expenses include:
  • Vision exam once per calendar year; and
  • Hearing exam once per calendar year.
A $250 calendar year maximum applies to out-of-network services per covered family member.
Skilled Nursing Facility Services
  • Room and board: Covered expenses for room and board are limited to the facility's regular daily charge for a semiprivate room.
  • Other services and supplies.
Covered services are limited to the first 120 days of confinement each calendar year.
Speech Therapy
Spinal Manipulations
Services of a physician given for the detection or correction (manipulation) by manual or mechanical means or structural imbalance or distortion of the spine. Routine maintenance and adjustments are not a covered service under this plan.
Surgery
Services for surgical procedures. (Oxford Health Plans: All surgical procedures must be precertified in advance.)
Reconstructive Surgery
  • Reconstructive surgery to improve the function of a body part when the malfunction is the direct result of one of the following:
    • Birth defect;
    • Sickness;
    • Surgery to treat a sickness or accidental injury; or
    • Accidental injury that happens while the person is covered under the plan,
  • Reconstructive breast surgery following a mastectomy including areolar reconstruction and the insertion of a breast implant. The plan covers expenses associated with reconstructive surgery following a mastectomy, expenses for reconstructive surgery on the other breast to achieve symmetry, the cost of prostheses, and the cost for treatment of physical complications at any stage of the mastectomy including lymphedemas. Plan deductibles, coinsurance, and copayments will apply; and
  • Reconstructive surgery to remove scar tissue on the neck, face, or head if the scar tissue is due to sickness or accidental injury that happens while the person is covered under the plan.
Assistant-Surgeon Services
Covered expenses for assistant-surgeon services are limited to 20% of the amount of covered expenses for the primary surgeon's charge for the surgery for non-HMO/PPO plans. An assistant-surgeon generally must be a licensed physician. Physician's-assistant services are not covered if billed on his or her own behalf. (Aetna and Anthem BlueCross BlueShield cover assistant surgeon services for certain surgeries. Aetna covers registered nurses acting as assistant surgeons for certain surgeries. Contact Anthem BlueCross BlueShield for information about which providers qualify as assistant surgeons.)
Multiple Surgical Procedure Guidelines
If you are using an out-of-network provider for a surgical procedure, the following multiple surgical procedure guidelines will apply.
If more than one procedure will be performed during one operation — through the same incision or operative field — the plan will pay according to the following guidelines:
  • First procedure: The plan will allow 100% of the negotiated or MAA.
  • Second procedure: The plan will allow 50% of the negotiated or MAA.
  • Third and additional procedures: The plan will allow 50% of the negotiated or MAA for each additional procedure.
  • Bilateral and separate operative areas: The plan will allow 100% of the negotiated or MAA for the primary procedure and 50% of the secondary procedure and 50% of the negotiated or MAA for tertiary/additional procedures.
If billed separately, incidental surgeries will not be covered. An incidental surgery is a procedure performed at the same time as a primary procedure and requires few additional physician resources and/or is clinically an integral part of the performance of the primary procedure.
Transsexual Surgery, Sex Change, or Transformation
The plan does cover procedures, treatments and related services designed to alter a participant's physical characteristics from his or her biologically determined sex to those of another sex.
Termination of Pregnancy
  • Voluntary (i.e., abortion) and
  • Involuntary (i.e., miscarriage).
Temporomandibular Joint Syndrome (TMJ)
Surgical treatment of TMJ does not include treatment performed by prosthesis placed directly on the teeth or physical therapy for TMJ.
Transgender Benefits
Transgender benefits are covered under the plan. The way the coverage is administered varies slightly between the carriers. This section describes specific coverage details for Aetna, Anthem Blue Cross Blue Shield, and Oxford.
Aetna: Aetna considers sex reassignment surgery medically necessary when all of the following criteria are met:
  • Member is at least 18 years old; and
  • Member has met criteria for the diagnosis of "true" transsexualism, including:
    • A sense of estrangement from one's own body, so that any evidence of one's own biological sex is regarded as repugnant; and
    • A stable transsexual orientation evidenced by a desire to be rid of one's genitals and to live in society as a member of the other sex for at least 2 years, that is, not limited to periods of stress; and
    • Absence of physical inter-sex of genetic abnormality; and
    • Does not gain sexual arousal from cross-dressing; and
    • Life-long sense of belonging to the opposite sex and of having been born into the wrong sex, often since childhood; and
    • Not due to another biological, chromosomal or associated psychiatric disorder, such as schizophrenia; and
    • Wishes to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and
  • Member has completed a recognized program of transgender identity treatment as evidenced by all of the following:
    • A qualified mental health professional1 who has been acquainted with the member for at least 18 months recommends sex reassignment surgery documented in the form of a written comprehensive evaluation; and
    • For genital surgical sex reassignment, a second concurring recommendation by another qualified mental health professional1 must be documented in the form of a written expert opinion2; and
    • For genital surgical sex reassignment, member has undergone a urological examination for the purpose of identifying and perhaps treating abnormalities of the genitourinary tract, since genital surgical sex reassignment includes the invasion of, and the alteration of, the genitourinary tract (urological examination is not required for persons not undergoing genital reassignment); and
    • Member has demonstrated an understanding of the proposed male-to-female or female-to-male sex reassignment surgery with its attendant costs, required lengths of hospitalization, likely complications, and post-surgical rehabilitation requirements of the planned surgery; and
    • Psychotherapy is not an absolute requirement for surgery unless the mental health professional's initial assessment leads to a recommendation for psychotherapy that specifies the goals of treatment, estimates its frequency and duration throughout the real life experience (usually a minimum of 3 months); and
    • For genital surgical sex reassignment, the member has successfully lived and worked within the desired gender role full-time for at least 12 months (so-called real-life experience), without periods of returning to the original gender; and
    • For genital surgical sex reassignment, member has received at least 12 months of continuous hormonal sex reassignment therapy recommended by a mental health professional and carried out by an endocrinologist (which can be simultaneous with the real-life experience), unless medically contraindicated.
Medically necessary core surgical procedures for female to male persons include: mastectomy, hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty, phalloplasty, urethroplasty, scrotoplasty and placement of testicular prostheses, and erectile prostheses.
Medically necessary core surgical procedures for male to female persons include: penectomy, orchidectomy, vaginoplasty, clitoroplasty, and labiaplasty.
Note: Rhinoplasty, face-lifting, lip enhancement, facial bone reduction, blepharoplasty, breast augmentation, liposuction of the waist (body contouring), reduction thyroid chondroplasty, hair removal, voice modification surgery (laryngoplasty or shortening of the vocal cords), and skin resurfacing, which have been used in feminization, are considered cosmetic. Similarly, chin implants, nose implants, and lip reduction, which have been used to assist masculinization, are considered cosmetic and are not covered.
Gender-specific services may be medically necessary for transgender persons appropriate to their anatomy. Examples include:
  • Breast cancer screening may be medically necessary for female to male transgender persons who have not undergone a mastectomy;
  • Prostate cancer screening may be medically necessary for male to female transgender individuals who have retained their prostate.
Anthem BlueCross BlueShield: Gender reassignment surgery1 is considered medically necessary when the all of the following criteria are met:
  • The patient is at least 18 years of age; and
  • The patient has been diagnosed with the Gender Identity Disorder (GID) of transsexualism, including all of the following:
    • The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and
    • The transsexual identity has been present persistently for at least two years; and
    • The disorder is not a symptom of another mental disorder or a chromosomal abnormality; and
    • The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and
  • For those patients without a medical contraindication, the patient has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician; and
  • The patient has completed a minimum of 12 months of successful continuous full time real-life experience in their new gender, with no returning to their original gender, including one or more of the following:
    • Maintain part- or full-time employment; or
    • Function as a student in an academic setting; or
    • Function in a community-based volunteer activity; and
  • The patient has acquired a legal gender-identity-appropriate name change; and
  • The patient has provided documentation to the treating therapist that persons other than the treating therapist know that the patient functions in the desired gender role; and
  • Regular participation in psychotherapy throughout the real-life experience when recommended by a treating medical or behavioral health practitioner; and
  • Demonstrable knowledge of the required length of hospitalizations, likely complications, and post-surgical rehabilitation requirements of various surgical approaches; and
  • Demonstrable progress in consolidating one's gender identity, including demonstrable progress in dealing with work, family, and interpersonal issues resulting in a significantly better state of mental health (this implies satisfactory control of problems such as sociopathy, substance abuse, psychosis, suicidality, for instance); and
  • A letter2 from the patient's physician or mental health provider, who has treated the patient for a minimum of 18 months, documenting the following:
    • The patient's general identifying characteristics; and
    • The initial and evolving gender, sexual, and other psychiatric diagnoses; and
    • The duration of their professional relationship including the type of psychotherapy or evaluation that the patient underwent; and
    • The eligibility criteria that have been met and the physician or mental health professional's rationale for surgery; and
    • The degree to which the patient has followed the eligibility criteria to date and the likelihood of future compliance; and
    • Whether the author of the report is part of a gender identity disorder treatment team; and
  • A letter2 from a second physician or mental health provider familiar with the patient's treatment and the psychological aspects of gender identity disorders, corroborating the information provided in the first letter; and
  • When one of the signatories on the letters indicated above is not the treating surgeon, a letter from the surgeon confirming that they have personally communicated with the treating mental health provider or physician, as well as the patient, and confirming that the patient meets the above criteria, understands the ramifications and possible complications of surgery, and that the surgeon feels that the patient is likely to benefit from surgery.
Gender reassignment surgery may include any of the following procedures:
  • Male-to-female procedures
    • Orchiectomy
    • Penectomy
    • Vaginoplasty
    • Clitoroplasty
    • Labiaplasty
  • Female-to-male procedures
    • Hysterectomy
    • Salpingo-oophorectomy
    • Vaginectomy
    • Metoidioplasty
    • Scrotoplasty
    • Urethroplasty
    • Placement of testicular prostheses
    • Phalloplasty
At least one of the professionals submitting a letter must have a doctoral degree (Ph.D., M.D., Ed.D., D.Sc., D.S.W., or Psy.D) and be capable of adequately evaluating co-morbid psychiatric conditions. One letter is sufficient if signed by two providers, one of whom has met the doctoral degree specifications, in addition to the specifications set forth above.
Not medically necessary:
  • Gender reassignment surgery is considered not medically necessary when one or more of the criteria above have not been met.
Cosmetic and not medically necessary:
  • The following surgeries are considered cosmetic and not medically necessary when used to improve the gender specific appearance of a patient who has undergone or is planning to undergo gender reassignment surgery:
    • Reduction thyroid chondroplasty
    • Liposuction
    • Rhinoplasty
    • Facial bone reconstruction
    • Face lift
    • Blepharoplasty
    • Voice modification surgery
    • Hair removal/hairplasty
    • Breast augmentation
Oxford: Covered services include:
  • Psychotherapy for gender identity disorders and associated co-morbid psychiatric diagnoses;
  • Continuous hormone replacement
    • Hormones of the desired gender;
    • Hormones injected by a medical provider (for example during an office visit) are covered by the medical plan. Benefits for these injections vary depending on the plan design.
    • Oral and self-injected hormones from a pharmacy are not covered under the medical plan. Refer to the Outpatient Prescription Drug Rider, or SPD for self-funded plans, for specific prescription drug product coverage and exclusion terms.
  • Genital surgery (by various techniques which must be appropriate to each patient), including:
    • Complete hysterectomy
    • Orchiectomy
    • Penectomy
    • Vaginoplasty
    • Vaginectomy
    • Clitoroplasty
    • Labiaplasty
    • Salpingo-oophorectomy
    • Metoidioplasty
    • Scrotoplasty
    • Urethroplasty
    • Placement of testicular prosthesis
    • Phalloplasty
  • Surgery to change specified secondary sex characteristics, specifically:
    • Thyroid chondroplasty (removal of the Adam's Apple); and
    • Bilateral mastectomy; and
    • Augmentation mammoplasty (including breast prosthesis if necessary) if the Physician prescribing hormones and the surgeon have documented that breast enlargement after undergoing hormone treatment for 18 months is not sufficient for comfort in the social role;
  • Laboratory testing to monitor the safety of continuous hormone therapy.
Hormone Replacement:
The covered person must meet all of the following eligibility qualifications for hormone replacement (in addition to the plan's overall eligibility requirements as shown in the plan document).
  • Age 18 years or older for hormones to change physical characteristics; and
  • Demonstrable knowledge of what hormones medically can and cannot do and their social benefits and risks; and
  • The covered person must meet the definition of gender identity disorder (see definition below); and
  • Initial hormone therapy must be preceded by:
    • A documented real-life experience (living as the other gender) of at least three months prior to the administration of hormones; or
    • A period of psychotherapy of a duration specified by the mental health professional after the initial evaluation (usually a minimum of three months).
Genital surgery and surgery to change secondary sex characteristics eligibility qualifications:
The covered person must meet all of the following eligibility qualifications for genital surgery and surgery to change secondary sex characteristics (in addition to the plan's overall eligibility requirements as shown in the plan document):
  • The surgery must be performed by a qualified provider at a facility with a history of treating individuals with gender identity disorder;
  • The treatment plan must conform to the World Professional Association for Transgender Health Association (WPATH) standards1;
  • The covered person must be age 18 years or older for irreversible surgical interventions;
  • The covered person must complete 12 months of continuous hormone therapy for those without contraindications;
  • The covered person must complete 12 months of successful continuous full time real life experience in the desired gender;
  • The covered person must meet the definition of Gender Identity Disorder (see definition below); and
  • The covered person's physician who is performing the surgery must follow the notification process prior to performing the surgery.
Exclusions:
The following treatments are not covered:
  • Reversal of genital surgery or reversal of surgery to revise secondary sex characteristics.
  • Sperm preservation in advance of hormone treatment or gender surgery.
  • Cryopreservation of fertilized embryos, except under the following circumstances:
    • Fertility preservation prior to gonadotoxic treatment including sperm, mature egg (women under the age of 42), or embryo cryopreservation with storage up to one year
  • Voice modification surgery.
  • Facial feminization surgery, including but not limited to: facial bone reduction, face "lift", facial hair removal, and certain facial plastic reconstruction.
  • Suction-assisted lipoplasty of the waist.
  • Rhinoplasty (except if rhinoplasty criteria is met as determined by Plan guidelines).
  • Blepharoplasty (except if blepharoplasty criteria is met as determined by Plan guidelines.)
  • Surgical or hormone treatment on enrollees under 18 years of age. Surgical treatment not prior authorized by Oxford.
  • Drugs for hair loss or growth.
  • Drugs for sexual performance or cosmetic purposes (except for hormone therapy described above.
  • Voice therapy.
  • Services that exceed the maximum dollar limit on the plan.
  • Transportation, meals, lodging or similar expenses.
1 At least one of the two clinical behavioral scientists making the favorable recommendation for surgical (genital) sex reassignment must possess a doctoral degree (e.g., Ph.D., Ed.D., D.Sc., D.S.W., Psy.D., or M.D.). Note: Evaluation of candidacy for sex reassignment surgery by a mental health professional is covered under the member's medical benefit, unless the services of a mental health professional are necessary to evaluate and treat a mental health problem, in which case the mental health professional's services are covered under the member's behavioral health benefit. Please check benefit plan descriptions.
2 Either two separate letters or one letter with two signatures is acceptable.
Treatment Centers
  • Room and board; and
  • Other services and supplies.
Voluntary Sterilization
  • Vasectomy; and
  • Tubal ligation.
Reversals are not covered.
Well-Child Care
Office visit charges for routine well-child care exams and immunizations based on guidelines from the American Medical Association.