Benefit

In-network

Out-of-network

Notes

Top Surgery

$250 Deductible

Coinsurance: 20%

Not Covered

Precertification required

Bottom Surgery

$250 Deductible

Coinsurance: 20%

Not covered

Precertification required

Gender Confirming Facial Surgery

$250 Deductible

Coinsurance: 20%

Not covered

Precertification/medical necessity requirements apply

Tracheal Shave

$250 Deductible

Coinsurance: 20%

Not covered

Precertification required

Electrolysis and laser hair removal

$250 Deductible

Coinsurance: 20%

Not covered

Precertification required

covered when medically  necessary

Vocal training

$25 copay per visit

No deductible

Not covered

-

Fertility preservation

$250 Deductible

Coinsurance: 20%

Not covered

Precertification required

Hormone therapy

$250 Deductible

Coinsurance: 20%

Not covered

Covered when medically necessary. Some services/medications may require precertification.

Psychotherapy

$0 copay + $0 deductible

Not covered

-

Hysterectomy

$250 deductible,

20% coinsurance

Not covered

Precertification required

Gender affirming surgery travel expenses

-Travel expense for each surgical procedure (limited to six trips)

-Transportation to the facility where the surgery will take place

-Lodging accommodations (limited to one room, double occupancy)

-Other reasonable expenses (excluding tobacco, alcohol, drug, and meal expenses)

-No copay, deductible, or coinsurance. Limited to 6 trips.

-Up to $250 for round-trip coach airfare per person. No deductible

-Up to $100 per day for up to 21 days per trip. Limited to one room, double occupancy. No deductible.

-Up to $25 per day, per person for up to 21 days per trip. No deductible

Not covered

Precertification required; specific limits apply