Consumer Driven Option Gender Affirming Care

APWU Health Plan recognizes that transgender, non-binary, and other gender diverse members require healthcare delivered by providers experienced in gender affirming health.

Gender affirming services include therapy to address feelings of gender dysphoria and medical treatments that help you achieve physical characteristics that better align with your gender identity.

Gender affirming surgery requires prior approval

Under the Consumer Driven Option, members need to call UnitedHealthcare before receiving gender affirming surgery. Failure to do so will result in a minimum $500 penalty for an inpatient hospital stay.

APWU Health Plan gender affirming services	Members pay
Benefits: Surgical treatment for gender affirmation Gender affirming surgery benefits are only available for the diagnosis of gender dysphoria Requirements: Prior approval is required. Must be at least 18 years of age at time prior approval is requested and treatment plan is submitted. Must have diagnosis of gender dysphoria by a qualified healthcare professional. Persistent, well-documented gender dysphoria. Member’s gender dysphoria is not a symptom of another mental disorder or chromosomal abnormality. Continuous hormone therapy as appropriate. Two clinical assessments from qualified healthcare professionals are required for genital and gonadal surgeries; all other surgeries require one assessment. If medical or mental health concerns are present, they are being optimally managed and are reasonably well-controlled.	In-network: 15% of the Plan allowance Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount
Not covered: Cosmetic services that are not medically necessary Travel and lodging	All charges

APWU Health Plan gender affirming services

Members pay

Benefits:

Surgical treatment for gender affirmation

Gender affirming surgery benefits are only available for the diagnosis of gender dysphoria

Requirements:

Prior approval is required.
Must be at least 18 years of age at time prior approval is requested and treatment plan is submitted.
Must have diagnosis of gender dysphoria by a qualified healthcare professional.
Persistent, well-documented gender dysphoria.
Member’s gender dysphoria is not a symptom of another mental disorder or chromosomal abnormality.
Continuous hormone therapy as appropriate.
Two clinical assessments from qualified healthcare professionals are required for genital and gonadal surgeries; all other surgeries require one assessment.
If medical or mental health concerns are present, they are being optimally managed and are reasonably well-controlled.

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Cosmetic services that are not medically necessary
Travel and lodging

All charges

Gender affirming services for the Consumer Driven Option plan

Gender affirming surgery requires prior approval

Federal brochure

Gender dysphoria treatment medical policy