Anthem Blue Cross Coverage

[Carolyn Marie]

I happened to be on their web site to check some pharmacy info, and clicked on the benefits page. There at the bottom of a long list of medical benefits was "Transgender Coverage." That's the first time I've ever seen it listed prominently.

The information contained was brief and just said that coverage for surgery was capped at $10,000. I suppose I would have to look at the fine print to find more information about non-surgical treatments such as HRT.

However, that isn't the final word on the subject. I recently had an orchiectomy for which Anthem paid $23,000, and they didn't bill me for a dime of it. Which is great, but which is also confusing, considering the limitations noted on their web site. There could be many reasons for the discrepancy.

Bottom line is this; don't assume your insurance company (especially in California) won't cover your expenses, or that a listed cap amount can't be worked around. Insurance is an area only experts can really figure out. We mortals are just left to hope that the Insurance Gods smile down on us and favor us with their largess.

Also note that every policy is different, so check yours carefully.

Carolyn Marie

[Guest CassieX]

Thanks Carolyn Marie for the update.

I'm patiently waiting for October, when many rules are supposed to change with regards to Transgender related treatments since that's when the new Diagnostic codes go live.

You can see the propsed codes here in Anthems current clinical guideline. It looks like they are overdue for an update. I am very interested to see how it translates into the FY15 Federal health insurance policies since the rules change on Transgender exclusions a couple of months ago.

http://www.anthem.com/medicalpolicies/guidelines/gl_pw_a051166.htm

HRT coverage is weird depending on your plan(s) coverage. On one of my meds it's free for a 90 day supply but I have to get it authorized every six months. Another is free and the last, the least expensive of the three according to pharmacy pricing, costs me a little over $9 for a 90 day supply. I spent a couple of hours on the phone trying to get that one clarified with my insurance and the best they could tell me is , "We don't know, the computers figure it out". So I guess Skynet controls our meds

Cassie

[Guest RalisTogari]

I have Anthem insurance as well. My therapy was covered and so was HRT although my prescription is one that requires authorization every few months too. I've been scheduled for top surgery next month and I'm actually surprised with how much my insurance covered. Dr. Peter Raphael in Plano, Tx will be performing my surgery and while he does accept Anthem insurance (the closest surgeon I was able to find who does) he's not an in-network doctor so I was expecting to pay more out of pocket.

The price I was quoted at my consultation in July was $6000. What I will actually have to pay on my pre-op appointment and surgery appointment are $502 and $792. Insurance really is a tricky thing.

[Guest Raging Shadow]

yea I have Blue Cross Blue Shield Federal Employee plan. specifically says it doesn't cover "sex transformation" anything. But they cover my horomones somehow. and I think CA passed a law that says they can't exclude trans coverage. hoping they will cover my hysto and phalloplasty while I'm still on my parents insurance (until 2022)

[Guest Megan_Lynn]

I happened to be on their web site to check some pharmacy info, and clicked on the benefits page. There at the bottom of a long list of medical benefits was "Transgender Coverage." That's the first time I've ever seen it listed prominently.

The information contained was brief and just said that coverage for surgery was capped at $10,000. I suppose I would have to look at the fine print to find more information about non-surgical treatments such as HRT.

However, that isn't the final word on the subject. I recently had an orchiectomy for which Anthem paid $23,000, and they didn't bill me for a dime of it. Which is great, but which is also confusing, considering the limitations noted on their web site. There could be many reasons for the discrepancy.

Bottom line is this; don't assume your insurance company (especially in California) won't cover your expenses, or that a listed cap amount can't be worked around. Insurance is an area only experts can really figure out. We mortals are just left to hope that the Insurance Gods smile down on us and favor us with their largess.

Also note that every policy is different, so check yours carefully.

Carolyn Marie

23k for an orchiectomy sounds way way high..sure it was not 2,300 insted? 23k can get one a complete srs/grs..

[Carolyn Marie]

.

23k for an orchiectomy sounds way way high..sure it was not 2,300 insted? 23k can get one a complete srs/grs..

I completely agree, Megan, and mentioned that in a post a while back. Yes, its correct. I found out that the surgeon had included a plastic surgery component to the bill. She had done some fancy stichery to keep things "flat" down there and less conspicuous. Apparently, it was worth a pretty penny, and the insurance company bought into it. Whatever passes muster, I suppose.

Carolyn Marie

[Guest Leah1026]

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23k for an orchiectomy sounds way way high..sure it was not 2,300 insted? 23k can get one a complete srs/grs..

I completely agree, Megan, and mentioned that in a post a while back. Yes, its correct. I found out that the surgeon had included a plastic surgery component to the bill. She had done some fancy stichery to keep things "flat" down there and less conspicuous. Apparently, it was worth a pretty penny, and the insurance company bought into it. Whatever passes muster, I suppose.

Carolyn Marie

This concerns me.

You see a several years ago everyone was hoping insurance would pay for surgery. I urged caution because I know how underhanded insurance companies can be. I argued that SRS was a bargain (then $17k) compared to other major surgery because we paid cash. I predicted that once insurance got the cost would go up dramatically and our "co-pay" would be.... $17k.

Be very careful out there and don't trust those insurance companies until surgery is done and all claims are settled.

[Guest LizMarie]

I think it was Dr. Marci Bowers who once admitted that in order to recover her typical costs (something like $24K right now?) she had to bill insurance companies nearly $100K and that after all was said and done she was lucky to get the cash equivalent back.

For profit health care in the United States is a massive scam. We are dead last among first world nations in numerous categories of health care, we have rising infant mortality rates, our lifespans have grown stagnant while every other first world nation continues to increase... and health insurance profits increased from about $2.5 billion in 2000 to over $12 billion in 2008. That's slipped a little since then due to the ACA mandating that a certain percentage of all premiums must be spent on actual health care but it's still far too messy and there are far too many financial leeches providing no added value to the health care chain by their existence.

Germany has a national health care system that's all privately funded, covers over 98% of all citizens, and they spend less than half of what we do to achieve significantly better health care. Naysayers like to point at the problems with Britain's NHS but they never want to talk about the immensely successful national health care systems in France, Germany, Japan, South Korea, etc. And those are hardly "socialist" nations, being among some of the strongest economies in the entire world, especially Germany, Japan, and South Korea.

I agree with Leah and I fully expect insurers to stick it to us as badly as they can even if GCS gets "covered" by insurance.

But hopefully by 2024 or so we'll finally get at least the option for a national single payer system. And when we do, expect the for-profit insurers to scream bloody murder as we take away their lollipop.

[Carolyn Marie]

This concerns me.

You see a several years ago everyone was hoping insurance would pay for surgery. I urged caution because I know how underhanded insurance companies can be. I argued that SRS was a bargain (then $17k) compared to other major surgery because we paid cash. I predicted that once insurance got the cost would go up dramatically and our "co-pay" would be.... $17k.

Be very careful out there and don't trust those insurance companies until surgery is done and all claims are settled.

Your concerns are valid, Leah. These issues are not unique to GRS, and have been reported frequently in the press. Doctors and hospitals pad the bills, the patient never sees it, and as long as the insurance company pays it, patients rarely ask any questions. If I had been paying out of pocket, I would have asked for the price before the surgery, and questioned the amount. I thought about talking to the insurance company about it, but ultimately decided to let the sleeping dog lay.

But we all end up paying in the end, because such practices are a major reason insurance premiums are so high. It's ridiculous, but Americans seem to think this is the best possible medical system. It gives me a headache, so I'll go take my prescription pain pill, the retail cost of which is about $100.

Carolyn Marie

[Guest JennaR]

For profit health care in the United States is a massive scam.

I completely agree. I have always argued that people's health, and indeed, their very lives should not be a for profit enterprise. Otherwise companies increase "shareholder value" by denying coverage, and doing everything else possible to intercourse over their customers. Too many people (i.e. complete and total morons) allow themselves to be brainwashed and fear mongered into screaming bloody murder over "federal overreach" and especially "socialism", while they happily enjoy our public funded roads, military, police, fire, and EMS services, as well as our public schools, etc. etc. So many people are content to continue with the "we're number one!" and "America is the greatest country on Earth" attitudes, when nearly every conceivable benchmark shows us to be at or near the bottom of the developed world. Until people wake up and realize America has fallen a very long way from its once lofty world position, I fear change will never come.

Jenna

[Guest CassieX]

Looking at the Federal Plans: There is only one Insurer that is multi agency and covers the majority of the Country, Aetna. BCBS completely dropped the ball this Fiscal Year. In Virginia I have 4 Aetna plans to choose from (3 realistically) that cover Transgender related treatments including surgery (once criteria for medical necessity is demonstrated). The average deductible after satisfying plan criteria ranges from 10%-40% with a catastrophic maximum cap on one of the plans of $5000. So realistically these plans cover everything except up to $5000 though they do not specify exactly how much they pay for the surgery. (potentiall caveat). For example, Christine McGinn currently charges $19500 for Vaginoplasty. I contacted her office last week and they still are looking for the full amount up front though they will precertify the hospital and Aetna has her surgery site in their preferred network. Dr. McGinn is not currently listed in their preferred doctor network in their online tool (I tried every conceivable search criteria). Since these plans do not go active until Jan 1st, 2015 I hope that there will be a shift in the surgeons policy of cash up front once they become more familiar with the insurance carriers new policies for surgery. I will be petitioning Aetna to get a list of their preferred surgeons who perform the surgery as they cannot realistically list a preferred and out of network price for the covered services and not retain any doctors who perform it in their network. That would potentially open the door for all sorts of legal challenges once the plans go live.

All this info is freely available on OPMs website http://www.opm.gov and can be found by clicking Insurance>Healthcare>Plan information and then clicking the state of coverage. Alternatively for Aetna you could go directly to http://www.aetnafeds.com/ and put in your zipcode.

Oh, and for the Aetna Direct Plan, with Medicare part A & B, the deductible is ZERO. So potentially, any Federal Job has never looked so good, especially for the folks that qualify for Medicare A & B (which I do not).

Hope all this info helps!

Cassie

[Guest fenambo]

I have Anthem Blue Cross Blue Shield of IL and it doesn't cover GRS. Every other Anthem plan WILL cover GRS. Is there any way I can get my insurance plan to cover mine? I also have an intersex condition. Since that is the case, would they be more willing to cover my surgeries?

[Carolyn Marie]

I have Anthem Blue Cross Blue Shield of IL and it doesn't cover GRS. Every other Anthem plan WILL cover GRS. Is there any way I can get my insurance plan to cover mine? I also have an intersex condition. Since that is the case, would they be more willing to cover my surgeries?

Have you already asked for approval for GRS, and has the company denied your claim. I think that often, the company reps will stick to the party line if you simply ask them a "what if" question. But if you get to the point of requesting approval, and then appeal if its denied initially, they will ultimately approve it. Be sure you talk to your doctor and get him/her to go to bat for you. i recently got denied a new diabetes medicine, but with my doctor on my side, the insurance company relented.

Never take "no" for an answer, unless you, and your doctor, have asked many times. It's all a big game to the insurance companies, who count on the fact that most people won't fight an initial denial of coverage.

Carolyn Marie

[Guest fenambo]

I haven't requested anything yet. I am waiting until after my total hysterectomy surgery. My doctor told me he can "slip me through the cracks of the system" to get my surgery covered. I don't want to screw that up.

[Guest]

However, that isn't the final word on the subject. I recently had an orchiectomy for which Anthem paid $23,000, and they didn't bill me for a dime of it.

Carolyn, I'm confused. I can't remember who it was but one or more of the admins here had mentioned that a full bottom SRS was around $20-$25K. How can an orchiectomy cost so much? Is this part of the 'markup' for people that have insurance?

[Carolyn Marie]

However, that isn't the final word on the subject. I recently had an orchiectomy for which Anthem paid $23,000, and they didn't bill me for a dime of it.

Carolyn, I'm confused. I can't remember who it was but one or more of the admins here had mentioned that a full bottom SRS was around $20-$25K. How can an orchiectomy cost so much? Is this part of the 'markup' for people that have insurance?

Yes, in all likelihood. As I noted in an earlier post, the doctor had billed extra for the "plastic surgery" part of the procedure, but I don't know how much of the additional cost she ascribed to that. Even with that, there is no way it should have cost that much. If I were paying out of pocket I would have gone yelling and screaming to her office. But the insurance company paid it and didn't bill me, so I was not about to raise a fuss.

Carolyn Marie

[Guest Lizzie McTrucker]

I have Anthem Blue Cross Blue Shield of IL and it doesn't cover GRS. Every other Anthem plan WILL cover GRS. Is there any way I can get my insurance plan to cover mine? I also have an intersex condition. Since that is the case, would they be more willing to cover my surgeries?

Have you already asked for approval for GRS, and has the company denied your claim. I think that often, the company reps will stick to the party line if you simply ask them a "what if" question. But if you get to the point of requesting approval, and then appeal if its denied initially, they will ultimately approve it. Be sure you talk to your doctor and get him/her to go to bat for you. i recently got denied a new diabetes medicine, but with my doctor on my side, the insurance company relented.

Never take "no" for an answer, unless you, and your doctor, have asked many times. It's all a big game to the insurance companies, who count on the fact that most people won't fight an initial denial of coverage.

Carolyn Marie

I'm going to have to keep this in mind. I have Anthem BCBS of Indiana and I'm pretty sure it's not covered but I just discovered that Dr. Greenwald in Tampa, who does GRS (and breast augmentation which is why I'm considering him) is an approved doctor under my health insurance.